What is the role of hyaluronic acid (HA) injections in treating osteoarthritis (OA) in older adults with a history of joint pain and comorbidities?

Hyaluronic Acid in Osteoarthritis

Hyaluronic acid (HA) injections should generally not be used for osteoarthritis treatment, as the highest quality evidence shows no meaningful benefit over placebo when studies with low risk of bias are analyzed. 1

Primary Recommendation by Joint Location

Knee Osteoarthritis

• The American College of Rheumatology conditionally recommends against HA injections for knee OA, based on meta-analyses showing that when limited to low-bias trials, the effect size compared to saline injections approaches zero. 1
• The apparent benefits seen in older systematic reviews were restricted to studies with higher risk of bias, and potential harms may be associated with these injections. 1
• HA may only be considered after exhausting all other options (nonpharmacologic therapies, topical NSAIDs, oral NSAIDs, and intraarticular corticosteroids) in the context of shared decision-making that acknowledges the limited evidence of benefit. 1

Hip Osteoarthritis

• HA injections are strongly recommended against for hip OA due to higher quality evidence demonstrating lack of benefit. 1
• This is a stronger prohibition than for knee OA and should not be offered. 1

First CMC Joint (Thumb Base)

• HA injections are conditionally recommended against for first carpometacarpal joint OA. 1

Treatment Algorithm When HA is Being Considered

Before considering HA, ensure the following have been tried:

1. Core non-pharmacological treatments (strengthening exercises, aerobic fitness, weight loss if overweight) 2
2. Topical NSAIDs (diclofenac gel) for effective pain relief with minimal systemic absorption, especially when oral NSAIDs are contraindicated 2, 3
3. Intraarticular corticosteroid injections for moderate to severe pain, particularly with inflammation and joint effusion, providing 2-4 weeks of relief 2, 3
4. Oral NSAIDs at lowest effective dose for shortest duration, if not contraindicated 4

If all above options have failed or are contraindicated:

• HA may be discussed as a last resort before opioids, recognizing it relies heavily on contextual/placebo effects 1
• Expected benefit is modest at best, with any improvement most likely between 5-13 weeks after treatment 5
• Duration of relief may extend up to 6 months in some patients 6

Critical Pitfalls to Avoid

• Do not use HA for hip OA under any circumstances - this is a strong recommendation against use. 1
• Do not offer HA as first-line or second-line therapy - it should only be considered after all evidence-based treatments have been exhausted. 2
• Do not be swayed by marketing claims - despite widespread availability and promotion, authoritative guidelines do not support routine use. 2
• Recognize the placebo effect - multiple studies demonstrate HA provides similar relief to placebo injections, and the contextual effects of receiving an injection may account for perceived benefits. 1, 5

Safety Profile

• Minor local side effects (pain and swelling lasting a few days) are common. 6
• Severe allergic reactions are extremely rare. 6
• Adverse events are generally less than 0.01% in reported series. 7

Evidence Quality Considerations

The 2019 American College of Rheumatology guideline represents the most authoritative and recent position, superseding the older 2001 American Geriatrics Society recommendation that suggested HA "has been shown to have efficacy." 1 The critical difference is that newer analyses accounting for study bias show no meaningful benefit. 1