What is the recommended use of steroids for osteoarthritis, including systemic versus intra‑articular injections?

Steroids for Osteoarthritis

Intra-articular corticosteroid injections are strongly recommended for knee and hip osteoarthritis to provide short-term pain relief (1-4 weeks), while systemic oral corticosteroids have no role in OA management. 1, 2

Intra-Articular Corticosteroids: The Preferred Approach

Indications and Efficacy

• Intra-articular glucocorticoid injections are strongly recommended for knee and hip OA based on Level 1A+ evidence from the American College of Rheumatology 2020 guidelines 1
• They are conditionally recommended for hand OA, though evidence is less robust for this location 1
• Injections are particularly indicated for acute flares of knee pain, especially when accompanied by effusion 2, 3
• The effect is clinically meaningful at 1 week post-injection but benefits are time-limited, typically lasting only 1-4 weeks with no long-term improvement at 2-year follow-up 1, 3, 4, 5

Preferred Agents and Dosing

For knee OA:

• Triamcinolone hexacetonide is the preferred agent when available, demonstrating more durable clinical responses than other formulations 3
• When hexacetonide is unavailable (currently the case in the US), use triamcinolone acetonide 40 mg or methylprednisolone 40 mg for large joints 2, 3, 6, 7
• Methylprednisolone shows improved pain and function at 4 and 24 weeks with longer duration than triamcinolone acetonide 3

For hip OA:

• Use 40 mg methylprednisolone for large joints 2
• Hip injections must always be performed under image guidance (ultrasound or fluoroscopy) - this is a strong recommendation 1, 2, 3

For hand OA:

• Lower doses are used for smaller joints, though specific dosing is not well established 2

Administration Technique

For knee injections:

• The superolateral (lateral midpatellar) approach is recommended, achieving 91-93% accuracy with anatomical landmarks alone 8
• Ultrasound guidance is optional for knee injections but improves accuracy (95.8% vs 77.8%) 8
• Strict aseptic technique is mandatory: use surgical gloves, prepare skin with alcohol/iodine/chlorhexidine, and change needles between drawing medication and injecting 8

For hip injections:

• Imaging guidance is mandatory - ultrasound or fluoroscopy must be used 1, 2

Safety Considerations and Important Caveats

Cartilage concerns:

• Recent evidence suggests intra-articular corticosteroids may be associated with MRI-assessed cartilage thickness loss 1, 9
• However, the American College of Rheumatology notes this finding lacks clinical significance because cartilage changes were not associated with worsening pain, function, or other radiographic features 1, 3

Frequency and timing:

• Avoid injection within 3 months preceding joint replacement surgery due to theoretical infection risk 2, 3
• Consider potential long-term negative effects on bone health, joint structure, and meniscal thickness with repeat administration 3
• The decision to reinject should consider benefits from previous injections and individualized factors 3

Post-injection instructions:

• Patients should avoid overuse of the injected joint for 24 hours, but complete immobilization is discouraged 2, 3

Comparison to Other Intra-Articular Treatments

Intra-articular corticosteroids are conditionally recommended over hyaluronic acid preparations because the evidence for glucocorticoid efficacy is considerably higher quality 1, 3

Systemic Corticosteroids: Not Recommended

Systemic (oral or intramuscular) corticosteroids have no established role in the routine management of osteoarthritis. 6, 7

• The FDA-approved indications for systemic corticosteroids do not include osteoarthritis as a primary indication 6, 7
• Systemic steroids may be mentioned only in the context of rheumatoid arthritis or acute gouty arthritis, not OA 6, 7
• The guidelines focus exclusively on intra-articular administration for OA management 1

Clinical Algorithm

1. For symptomatic knee or hip OA with acute flare:

   • Offer intra-articular corticosteroid injection as second-line or combination therapy 3
   • Use methylprednisolone 40 mg or triamcinolone acetonide 40 mg 2, 3
   • For knee: use superolateral approach with or without ultrasound 8
   • For hip: mandatory image guidance 1, 2

2. Set appropriate expectations:

   • Inform patients that benefit lasts 1-4 weeks on average 1, 3, 4
   • Short-term relief is the goal; no long-term disease modification 3

3. Avoid in specific circumstances:

   • Within 3 months of planned joint replacement 2, 3
   • Exercise caution with frequent repeat injections due to potential cartilage effects 1, 9