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Hyaluronic Acid Injections for Osteoarthritis

The weight of evidence suggests that a shot in the knee may bring some OA patients relief

Joints are like gears – they work best if they’re well lubricated In a healthy joint, a thick substance called synovial fluid provides lubrication, allowing bones to glide against one another Synovial fluid acts as a shock absorber, too In people with osteoarthritis, a critical substance in synovial fluid known as hyaluronic acid breaks down Loss of hyaluronic acid appears to contribute to joint pain and stiffness

An Alternative to NSAIDs

Hyaluronic acid injections are one treatment option doctors may offer when a patient is no longer able to control osteoarthritis pain with ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs), or the patient can’t tolerate these drugs (which can cause side effects such as stomach bleeding and kidney problems) The treatment regimen for hyaluronic acid usually involves receiving one injection in the affected joint per week for three to five weeks Many patients appear to get at least some relief – eventually

As a patient soon learns, though, hyaluronic acid is no quick fix According to Bellamy’s review (which was conducted on behalf of the Cochrane Collaboration, an international consortium that reviews scientific evidence for medical treatments), it takes about five weeks, on average, before a patient experiences the full benefits of hyaluronic acid By contrast, corticosteroid injections – the other primary treatment choice when NSAIDs aren’t an option – provide significant relief within a few days However, pain relief from corticosteroids diminishes markedly within a month or so What’s more, overuse of corticosteroids can have a catabolic effect – that is, it could cause cartilage to break down and deteriorate further, explains Case Western Reserve University rheumatologist Roland W Moskowitz, MD Meanwhile, the Cochrane review found that pain-relieving benefits of hyaluronic acid persist at peak levels for about three months, on average Dr Moskowitz sometimes gives patients a double shot in the knee – one injection each of hyaluronic acid and corticosteroids – for quick-acting, long-lasting relief

Variable Response

Hower, hyaluronic acid isn't universally approved In June 2013, the American Academy of Orthopedic Surgeons (AAOS) issued a new set of recommendations for the treatment of knee OA Based on a review of 14 studies, the organization determined hyaluronic acid did not meet the minimum clinically important improvement measures, according to David S Jevsevar, MD, chair of the evidence-based practice committee for the AAOS

With five brands available in the United States, it’s natural to ask which is most effective There have been relatively few head-to-head comparisons of the various products in clinical trials “My sense is that they all work about the same,” says Dr Jevsevar, a view shared by many other physicians who use the treatments Likewise, the risk of side effects is similar among the different products, the most common being pain and swelling at the injection site that fades within a few days

Beyond the question of how well viscosupplements work lies another intriguing area of inquiry: How do they work? Hyaluronic acid may act as a lubricant and shock absorber, but “there’s more to it than that,” says Dr Moskowitz “Hyaluronic acid has a lot of other activities in the joint” For example, research suggests that hyaluronic acid interfere with prostaglandins and cytokines, naturally occurring compounds that promote inflammation

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