Is steroid treatment effective for osteoarthritis (OA)?

Steroid Treatment for Osteoarthritis

Intra-articular corticosteroid injections are effective for short-term pain relief in osteoarthritis but provide only temporary benefit lasting 1-4 weeks. 1

Efficacy of Intra-articular Corticosteroids

• Intra-articular corticosteroid injections are strongly recommended for patients with knee and hip OA, and conditionally recommended for hand OA 1
• Evidence shows clinically important and statistically significant effects on pain reduction at 1 week after injection, with effect sizes of up to 1.27 compared to placebo 1
• Benefits typically last for 1-4 weeks, with significant differences in pain relief between steroid and placebo after one and four weeks, but minimal evidence for longer-term benefits 1
• Particularly effective for acute exacerbations of knee pain, especially when accompanied by effusion 1, 2

Administration Considerations

• Ultrasound guidance is strongly recommended for hip joint injections to ensure accurate medication delivery 1
• Imaging guidance is not required for knee and hand joint injections 1
• When comparing different injection options, intra-articular corticosteroids are conditionally recommended over other forms of intra-articular injection (including hyaluronic acid) for knee, hip, and hand OA 1

Patient Selection

• While some studies suggest better outcomes in patients with effusion, other research indicates that steroid injection should not be limited only to those with effusion 1
• The American College of Rheumatology recommends assessing the knee for presence of effusion, pain, and inflammatory signs to guide treatment approach 2
• Particularly useful for patients with acute flares of pain and inflammation 1

Safety Considerations

• A recent report raised concerns that specific steroid preparations or frequent injections may contribute to cartilage loss, though the clinical significance remains uncertain 1
• Long-term repeated injections should be approached with caution due to potential harm 3
• Patients with diabetes should have glucose levels monitored for 1-3 days after corticosteroid injections due to potential transient hyperglycemia 2
• Patients should avoid overuse of the injected joint for 24 hours following intra-articular therapy 2
• Corticosteroid injections should be avoided within 3 months prior to knee replacement surgery due to increased infection risk 2

Treatment Algorithm

1. First-line treatment: Start with non-pharmacological approaches and oral analgesics like acetaminophen (up to 4g/day) 2
2. Second-line treatment: Consider NSAIDs (oral or topical) for patients unresponsive to acetaminophen, especially with effusion 2
3. Third-line treatment: Use intra-articular corticosteroid injection for acute exacerbations of pain, particularly with effusion 1
4. For persistent symptoms: Consider repeat injections if previous injection provided relief, but be cautious about frequent repeated injections 2, 3
5. For refractory cases: Consider joint replacement for patients with radiographic evidence of OA who have persistent pain and disability despite conservative measures 1

Comparison with Other Treatments

• Methylprednisolone injections show better short-term results compared to hyaluronic acid, while hyaluronic acid may provide better long-term benefits 4
• Intra-articular corticosteroids are conditionally recommended over other forms of intra-articular injection, including hyaluronic acid preparations, based on higher quality evidence 1
• For most individuals with OA, acetaminophen alone may be ineffective, making other interventions necessary 1

Common Pitfalls

• Expecting long-term benefits from corticosteroid injections when evidence supports only short-term relief (1-4 weeks) 1
• Overuse of repeated injections without considering potential cartilage damage 1, 3
• Failing to use imaging guidance for hip injections, which can lead to inaccurate medication delivery 1
• Not considering the phasic nature of osteoarthritis when timing steroid injections 5