Can Durolane (hyaluronic acid) be administered with cortisone?

Durolane and Cortisone Co-administration in Joint Injections

Durolane (hyaluronic acid) can be safely administered with cortisone (corticosteroid) injections, and this combination may provide better pain relief than hyaluronic acid alone for osteoarthritis treatment.

Evidence for Combined Administration

• Combined intra-articular injections of corticosteroid and hyaluronic acid have demonstrated greater pain reduction at 2-4 weeks, 24-26 weeks, and up to 52 weeks compared to hyaluronic acid injections alone 1
• In veterinary medicine, the combination of hyaluronic acid and cortisone has shown significantly better improvement in traumatic arthritis compared to cortisone alone 2
• The combination approach may provide both rapid onset of pain relief (from corticosteroid) and longer-lasting benefits (from hyaluronic acid) 3

Mechanism and Benefits

• Corticosteroids provide rapid anti-inflammatory effects that can quickly reduce pain and swelling in the joint 4
• Hyaluronic acid (Durolane) provides viscosupplementation that may help with longer-term pain relief and potentially improve joint function 3
• Durolane specifically has the advantage of requiring only a single injection compared to other hyaluronic acid products that may require multiple injections 3, 5

Clinical Applications

• For osteoarthritis of the knee, the combination of intra-articular corticosteroid with hyaluronic acid may be considered when either treatment alone provides inadequate relief 1
• For trapeziometacarpal (thumb base) joint osteoarthritis, intra-articular corticosteroid injections have shown effectiveness for painful flares 4
• In clinical practice, the combination may be particularly useful for patients with acute pain exacerbations who also need longer-term symptom management 4

Important Considerations and Precautions

• The American College of Rheumatology conditionally recommends against intra-articular hyaluronic acid injections for knee and first carpometacarpal joint osteoarthritis, and strongly recommends against them for hip osteoarthritis due to limited evidence of benefit 4, 6
• However, guidelines acknowledge that hyaluronic acid injections may still be considered when other treatments have failed to provide adequate symptom relief 6
• When administering corticosteroids, consider the patient's overall health status, particularly in those with diabetes, as glucocorticoids can cause hyperglycemia 4
• For patients on oral steroids or with adrenal insufficiency, additional systemic steroid coverage may be needed when administering intra-articular corticosteroids during the perioperative period 4

Treatment Algorithm

1. First-line treatments: Begin with non-pharmacologic interventions, topical and oral NSAIDs before considering intra-articular injections 6, 7
2. Second-line treatment: Consider intra-articular corticosteroid injection alone for acute pain relief 4
3. Third-line treatment: For patients with inadequate response to corticosteroid injection alone, consider:
   • Hyaluronic acid injection alone 4, 6
   • Combined corticosteroid and hyaluronic acid injection for potentially better pain relief 1

Dosing Considerations

• When combining treatments, standard doses of both medications can be used 1
• For Durolane specifically, a single 3ml injection is typically administered 5
• For corticosteroids, dosing depends on the joint size and specific corticosteroid formulation 4
• The combination can be administered as a single injection containing both medications 1

In conclusion, while current guidelines conditionally recommend against hyaluronic acid injections as a first-line therapy, the combination of Durolane with corticosteroid is safe and may provide better pain relief than either treatment alone for patients who have failed other conservative treatments.