What is the recommended dose of corticosteroids (CS), such as prednisone, for treating osteoarthritis (OA)?

Corticosteroid Dosing for Osteoarthritis

Intra-articular Corticosteroid Injections for Osteoarthritis

For osteoarthritis, intra-articular corticosteroid injections are the recommended approach, particularly for acute exacerbations of knee pain accompanied by effusion. 1, 2

Indications and Benefits:

• Intra-articular corticosteroid injections are effective for acute exacerbations of knee pain, especially when accompanied by effusion 1, 2
• These injections provide short-term pain relief lasting approximately 1-3 weeks 3
• They should be considered as an advanced treatment option when first-line treatments (acetaminophen, NSAIDs, exercise) have failed 2

Recommended Corticosteroid Preparations:

• Longer-acting preparations are preferred over hydrocortisone acetate 4:
  • Methylprednisolone acetate
  • Triamcinolone acetonide
  • Triamcinolone hexacetonide (most effective but requires experienced clinicians due to risk of tissue necrosis if injected outside the joint) 4

Dosing Limitations:

• Injections into the same joint should be limited to 4:
  • No more than 1 injection every 6 weeks
  • No more than 3-4 injections per year in the same joint

Post-Injection Recommendations:

• Avoid overuse of injected joints for 24 hours following injection, but immobilization is discouraged 1
• Monitor glucose levels particularly from the first to third day after injection in patients with diabetes 1

Oral Corticosteroids for Osteoarthritis

While intra-articular injections are the primary corticosteroid approach for osteoarthritis, recent evidence supports short-term oral corticosteroid use in specific situations:

• For inflammatory hand osteoarthritis, short-term treatment with 10 mg prednisolone daily for 6 weeks has been shown to be effective for pain reduction 5, 6
• This approach should be considered only for patients with signs of inflammation (soft swelling, erythema, or positive power Doppler signal on ultrasound) 6
• After the 6-week treatment period, a 2-week tapering scheme is recommended 6

Treatment Algorithm for Osteoarthritis

1. First-line treatments 2:

   • Acetaminophen (up to 4,000 mg/day)
   • Exercise therapy focusing on quadriceps strengthening
   • Weight loss for overweight patients

2. Second-line treatments 2:

   • Topical NSAIDs (particularly in patients ≥75 years)
   • Oral NSAIDs with gastroprotective agents if needed

3. Advanced treatments 1, 2, 4:

   • Intra-articular corticosteroid injections for acute flares with effusion
   • For hand osteoarthritis with inflammatory signs, consider short-term oral prednisolone (10 mg daily for 6 weeks) 5, 6

Important Considerations and Precautions

• Strict aseptic technique is essential when performing intra-articular injections to avoid iatrogenic septic arthritis 4
• Intra-articular therapy is not contraindicated in people with clotting/bleeding disorders or taking antithrombotic medications, unless bleeding risk is high 1
• Intra-articular injections may be performed at least 3 months prior to joint replacement surgery 1
• For oral corticosteroid administration, consider taking with food or milk to reduce gastric irritation 7
• When using oral corticosteroids, administer in the morning (before 9 am) to minimize adrenal suppression 7
• Consider calcium and vitamin D supplementation to minimize osteopenia risk with oral corticosteroid use 8