Viscosupplementation with hyaluronans for osteoarthritis of the knee: clinical efficacy and economic implications

May the Symptomatic Subtalar Joint Be Conservatively Treated With Intra-Articular Hyaluronic Acid Injections After a Calcaneus Fracture?

BACKGROUND

Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture.

METHODS

We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection.

RESULTS

Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week (P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week (P = .001).

CONCLUSION

For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement.

LEVEL OF EVIDENCE

IV, Case series.

The Effects of Ultrasound-Guided Intra-Articular Injections with Hyaluronic Acid and Corticosteroids in Patients with Hip Osteoarthritis: A Long-Term Real-World Analysis

Intra-articular (IA) ultrasound-guided hip injections are currently considered a cornerstone of the conservative management of symptomatic hip osteoarthritis (HOA), although their effect on clinical outcomes has not been fully elucidated.The purpose of this study is to investigate the effectiveness of ultrasound-guided IA hip injections of hyaluronic acid (HA) with or without corticosteroids (CS) on pain relief and functional improvement in patients with HOA. In total, 167 patients with HOA were assessed at baseline (T0) and 12 months after injection (T1) using the VAS and GLFS scores. The sample consisted mainly of female subjects (58.1%), presenting an average age of 70.6 ± 12.2 years and grade 3 HOA (63.9%) according to the Kellgren-Lawrence classification. Most of the patients (76.2%) underwent unilateral hip injection with a combination of medium-high molecular weight HA (1500-2000 kDa) and CS. At T1, lower use of anti-inflammatory drugs, an increase in the consumption of chondroprotectors, and an overall reduction of instrumental physical therapies and therapeutic exercise were recorded. In addition, a statistically significant intragroup and between-group decrease observed at T1 for both the VAS and GLFS. Study results suggested that intra-articular hip injections with HA alone and with CS could represent a useful therapeutic tool for pain reduction and functional improvement for patients with hip osteoarthritis.

Efficacy and safety of platelet-rich plasma combined with hyaluronic acid versus platelet-rich plasma alone for knee osteoarthritis: a systematic review and meta-analysis

Purpose

To systematically evaluate the curative efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA), comparing with platelet-rich plasma alone.

Methods

Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI) and Embase were searched for randomized controlled trials (RCTs) and cohort studies regarding the efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA) comparing with platelet-rich plasma alone before January 15, 2022. The methodological quality of the ultimately included studies was assessed comprehensively, and meta-analysis was implemented using RevMan 5.3 software.

Results

Thirteen articles (9 RCTs, 4 cohort studies), including 1118 patients, were covered. There was no significant difference between the PRP + HA therapy and PRP-alone therapy in VAS scores at 3 months, 6 months and 12 months, WOMAC total scores at 3 months and KOOS at 1 month and 6 months. Compared with PRP-alone therapy, PRP + HA therapy was associated with significantly better improvement in VAS scores at 1 month, WOMAC total scores at 6 months, KOOS at 3 months, IKDC scores at 6 months and Lequesne index scores at 3 and 6 months. However, the smallest treatment effect of VAS scores, WOMAC total scores, KOOS and IKDC scores did not exceed the minimum clinically important difference (MCID). However, PRP + HA therapy got a greater reduction in the rate of adverse events, compared with PRP-alone therapy.

Conclusion

The results of this meta-analysis indicated that PRP + HA therapy was not found to be superior to PRP-alone therapy in pain relief and function improvement for patients with KOA. However, combined PRP with HA injections was generally safer than PRP injections alone, by assessing the incidence of adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03398-6.

Evaluation of Hylan G-F 20 Treatment with Opioid Prescriptions and Intraarticular Corticosteroid Injections in Patients with Osteoarthritis of the Knee Using a Claims Database

OBJECTIVE

Assess how treatment with the viscosupplement hylan G-F 20 relates to opioid prescriptions and intraarticular corticosteroid injections (IACS) in patients with osteoarthritis of the knee (OAK).

DESIGN

Case-crossover; adult patients with OAK identified in a claims database were treated with hylan G-F 20 from July 1, 2007, to June 29, 2017. Opioid or IACS prescriptions in the 6 months before treatment were compared to the 6 months after. Patients with comorbid conditions requiring pain medications were excluded, resulting in a 29,395-patient cohort. Four subgroups were investigated: patients with (1) opioids before hylan G-F 20 (OB; n = 6,609); (2) opioids before and after hylan G-F 20 (OBF; n = 3,320); (3) IACS before hylan G-F 20 (CB; n = 11,162); and (4) IACS before and after hylan G-F 20 (CBF; n = 2,810). All opioids were converted to morphine milligram equivalents (MME).

RESULTS

OB subgroup patients had a significant decrease (P < 0.01) in total MME (-14.0%), MME per day (-14.2%) and opioid prescription days (-12.6%) after treatment versus before. Only 50.2% of patients prescribed opioids before hylan G-F 20 were prescribed an opioid after treatment. OBF subgroup patients had a significant increase (P < 0.01) in opioid prescription days (7.8%) before versus after treatment. There was a significant decrease (P < 0.01) in the number of IACS after versus before treatment for the Total Cohort (-56.1%), and subgroups CB (-72.6%) and CBF (-4.1%). A total of 74.8% of patients receiving an IACS before treatment did not receive an IACS after treatment.

CONCLUSIONS

Hylan G-F 20 is associated with a reduction in opioid prescriptions and IACS in OAK patients.

Hyaluronic Acid In Vitro Response: Viability and Proliferation Profile of Human Chondrocytes in 3D-Based Culture

OBJECTIVES

This study aimed to evaluate the efficacy of hyaluronic acid in the viability and proliferation profile of human femoral-tibial joint cartilage affected by osteoarthritis using in vitro models of chondrocytes in a 2-dimensional (2D)- and 3-dimensional (3D)-based culture model by spheroids.

DESIGN

In vitro study of knee cartilage affected by osteoarthritis that required surgical treatment. Samples were cultured and exposed to hyaluronic acid (100 and 500 μM; intervention group) or vehicle solution. In monolayer or 2D culture, proliferation and cell viability were measured, and nuclear morphometry was analyzed by 4',6'-diamino-2-fenil-indol (DAPI) staining. The 3D-based culture established from the culture of articular cartilage of patients submitted to total knee arthroplasty evaluated the diameter, viability, and fusion ability of the chondrospheres created.

RESULTS

Samples from 3 patients resulted in viable cultures, with chondrocyte cells exhibiting a potential for cell proliferation and viability to establish a culture. Hyaluronic acid (100 and 500 μM) improved chondrocyte viability and proliferation up to 72 hours in contact when compared with the control group, and no nuclear irregularities in morphology cell characteristics were observed by DAPI. In the 3D evaluation, hyaluronic acid (500 μM) improved the cellular feedback mechanisms, increasing the survival and maintenance of the chondrospheres after 7 days of analysis, showing the intrinsic capacity of chondrospheres grouped in the attempt to rearrange and reestablish new articular tissue.

CONCLUSIONS

The 2D- and 3D-based culture models with hyaluronic acid improved chondrocyte viability and proliferation and demonstrated the ability of freshly formed chondrospheres to undergo fusion when placed together in the presence of hyaluronic acid.

Pharmacological Management of Osteoarthritis With a Focus on Symptomatic Slow-Acting Drugs: Recommendations From Leading Russian Experts

BACKGROUND

This article describes an updated stepwise algorithm for the pharmacological management of osteoarthritis (OA) to establish a treatment method for patients with OA.

SUMMARY

In step 1, background maintenance therapy includes symptomatic slow-acting drugs for OA, especially prescription crystalline glucosamine sulfate product, for which the high-quality evidence base of efficacy is unequivocal, or prescription chondroitin sulfate. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol only as rescue analgesia is given on top of the background therapy. Step 2: For patients with persistent OA symptoms, the use of oral NSAIDs is mandatory for maintaining supportive therapy with symptomatic slow-acting drugs for OA. It is recommended to properly stratify patients and carefully select oral NSAID therapy to maximize the benefit-to-risk ratio. Intra-articular hyaluronic acid and intra-articular corticosteroids are recommended as well in step 2 of the algorithm, especially for patients who do not respond to the previous therapies. Step 3: Duloxetine is considered along with the previous procedures, especially in patients with pain from central sensitization. Step 4: Total joint replacement is recommended for patients with severe symptoms and poor quality of life.

MAJOR CONCLUSIONS

The current guidelines and literature review provide evidence-based recommendations supported by clinical experience on how to organize the treatment process in patients with knee OA applicable in the Russian clinical practice.

FUTURE RESEARCH DIRECTIONS

International evidence-based guidelines lack consensus on different treatments, including the use of prescription crystalline glucosamine sulfate, NSAIDs, and intra-articular hyaluronic acid. The content of this article needs a further discussion about the clinical evidence and harmonization of recommendations for knee OA management.

Intraarticular Corticosteroids for Hip Osteoarthritis: A Review

INTRODUCTION

Hip osteoarthritis is a prevalent condition responsible for important pain and disability. Most available guidelines for nonsurgical management of hip osteoarthritis recommend a combination of nonpharmacological and pharmacological treatment modalities. Intraarticular corticosteroid injections have been used for decades, although evidence is quite scarce, and many controversies remain.

METHODS

This article reviews the available literature from Medline and Embase and discusses the evidence for intraarticular corticosteroid injections in hip osteoarthritis, where only 5 randomized controlled trials were found in the literature. These are analyzed in this article, which also aims to explain the main characteristics and features of glucocorticoids, along with their contraindications and potential adverse effects.

RESULTS

Available randomized controlled trials show that intraarticular corticosteroid injections provide pain relief and functional improvement in hip osteoarthritis. This efficacy has not been shown with intraarticular hyaluronic acid injections.

CONCLUSION

This review shows that intraarticular corticosteroid injections are efficacious in hip osteoarthritis and that this benefit can last up to 12 weeks.

High-Molecular-Weight Hyaluronic Acid Inhibits IL-1β-Induced Synovial Inflammation and Macrophage Polarization through the GRP78-NF-κB Signaling Pathway

Recent evidence has suggested that synovial inflammation and macrophage polarization were involved in the pathogenesis of osteoarthritis (OA). Additionally, high-molecular-weight hyaluronic acid (HMW-HA) was often used clinically to treat OA. GRP78, an endoplasmic reticulum (ER) stress chaperone, was suggested to contribute to the hyperplasia of synovial cells in OA. However, it was still unclear whether HMW-HA affected macrophage polarization through GRP78. Therefore, we aimed to identify the effect of HMW-HA in primary synovial cells and macrophage polarization and to investigate the role of GRP78 signaling. We used IL-1β to treat primary synoviocytes to mimic OA, and then treated them with HMW-HA. We also collected conditioned medium (CM) to culture THP-1 macrophages and examine the changes in the phenotype. IL-1β increased the expression of GRP78, NF-κB (p65 phosphorylation), IL-6, and PGE2 in primary synoviocytes, accompanied by an increased macrophage M1/M2 polarization. GRP78 knockdown significantly reversed the expression of IL-1β-induced GRP78-related downstream molecules and macrophage polarization. HMW-HA with GRP78 knockdown had additive effects in an IL-1β culture. Finally, the synovial fluid from OA patients revealed significantly decreased IL-6 and PGE2 levels after the HMW-HA treatment. Our study elucidated a new form of signal transduction for HMW-HA-mediated protection against synovial inflammation and macrophage polarization and highlighted the involvement of the GRP78-NF-κB signaling pathway.

The use of biologics to improve patient-reported outcomes in hip preservation

Despite lack of clear understanding, the use of biologic treatment methods has increased in the United States. Therapeutic methods, including platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and hyaluronic acid (HA) among other biologics, are commonly associated with relief of pain in a number of different orthopedic conditions. Within the past two decades, hip preservationists have investigated the roles of these biologic treatments in both non-operative and surgical management of common hip conditions. The purpose is to review the published literature surrounding the application and efficacy of biologics, most notably PRP, BMAC and HA, in the clinical management of hip conditions. The hip conditions examined in this review include hip osteoarthritis, femoroacetabular impingement syndrome and associated labral tear pathology, avascular necrosis of the femoral head and gluteal/hamstring tendinopathy. While our review of the literature suggests that there is support for the implementation of biologics to relieve pain and improve function for hip conditions. Through further research efforts, it is important to stay updated with the clinical efficacy of biologics in hip preservation.

The effect of viscosupplementation on early-stage knee osteoarthritis: Clinical evaluation and assessment of cartilage in vivo with 7 T MRI

INTRODUCTION

Viscosupplementation is a well-known strategy for managing early stages knee Osteoarthritis. However, despite its effectiveness in reducing symptoms, it has not yet been found to have an effect on joint cartilage. The aim of this study is to evaluate the clinical efficacy of a new product with gel-like behaviour and its in vivo effects on joint cartilage.

METHODS

20 patients were treated by 2 consecutive injections of hyaluronan derivative Hymovis® at one-week interval. Clinical evaluation was performed before the treatment and at each time point during the follow-up using WOMAC and VAS. A 7 T magnet was used for cartilage evaluation at each MRI time point: T2 Relaxation Time (RT), T2∗ RT and cartilage parameters were evaluated before the first injection, after 45 days and at 6 months follow-up. Statistical analysis was obtained for each reported data.

RESULTS

We report significantly reduction in symptoms with an increase in knee and global activity functions. The T2 RT for lateral tibial compartment and T2∗ RT for Patello-Femoral compartment significantly decreased. A T2 RT reduction was observed in all knee compartments except for the medial tibial one, while a T2∗ RT reduction was observed in all knee compartments. We report an increase in cartilage volume and thickness in most of patients with a reduction of cartilage defects in 9 patients, but we didn't find MRI signals clearly referable to cartilage regeneration.

CONCLUSIONS

MRI results have confirmed the possibility to employ 7T magnets to evaluate early changes in cartilage structure in vivo. HA VS has provided good clinical outcomes and an improvement in the global assessment of the knee joint, but it doesn't seem to significantly modify the cartilage over the time.

Effect of a single intra-articular high molecular weight hyaluronan in a naturally occurring canine osteoarthritis model: a randomized controlled trial

BACKGROUND

Osteoarthritis (OA) is a complex joint disease and chronic pain source, affecting a patient's quality of life and posing a financial burden. As the dog is considered a nearly ideal species for translation research of human OA and the most used model for research, exploring spontaneous dog OA under the One Health/One Medicine concept can improve both humans and dogs' health and well-being.

METHODS

In a clinical treatment experiment, forty (N=40) joints were selected and randomly assigned to a control group (CG), which received 0.9% NaCl or a treatment (HG), which received Hylan G-F 20. Evaluations were performed on treatment day (T0), 8, 15, 30, 90, and 180 days post-treatment. They consisted of four different Clinical Metrology Instruments (CMI), evaluation of weight distribution, joint range of motion, thigh girth, radiographic and digital thermography imaging, synovial fluid interleukin-1 (IL-1), and C-reactive protein concentrations. Results were compared with repeated measures ANOVA, with a Huynh-Feldt correction, Paired samples T-test, or Wilcoxon signed-ranks test, with p<0.05.

RESULTS

Patients had a mean age of 6.5±2.4 years and a bodyweight of 26.6±5.2kg, and joints graded as mild (n=28, 70%), moderate (n=6, 15%), and severe OA (n=6, 15%). No differences were found between groups at T0. Symmetry index and deviation showed significant improvements in HG from 30 days (p<0.01) up to 180 days (p=0.01). Several CMI scores, particularly pain scores, improved from 90 to 180 days. Radiographic signs progressed in both groups. In both groups, increasing body weight and age corresponded to worse clinical presentation. IA hyaluronan administration produced increased lameness in six cases, which resolved spontaneously.

CONCLUSIONS

This study characterizes the response to treatment with Hylan G-F 20, which can produce significant functional and pain level improvements in patients with OA, even those with factors related to worse response to treatment.

Orthobiologics in the treatment of hip disorders

Orthobiologics are biological materials that are intended for the regeneration or healing of bone, cartilage and soft tissues. In this review we discuss the use of orthobiologics for hip disorders providing an update. The orthobiologics included in this article are hyaluronic acid, platelet rich plasma, bone marrow, adipose tissue and expanded mesenchymal stem cells. We explain the concepts and definitions of each orthobiological product, and the literature regarding its use in the hip joint. The paucity of guidelines for the production and characterization of the biological products leads to uneven results across the literature. Each biologic therapy has indications and benefits; however, noteworthy are the characterization of the orthobiologics, the application method and outcome analysis for further improvement of each technique.

Platelet-Rich Plasma Combined With Hyaluronic Acid Improves Pain and Function Compared With Hyaluronic Acid Alone in Knee Osteoarthritis: A Systematic Review and Meta-analysis

PURPOSE

To evaluate the efficacy of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) injections versus HA injections alone for the management of knee osteoarthritis (OA).

METHODS

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies directly comparing combined PRP-HA injections with HA injections alone were identified through a search of PubMed, Scopus, and Cochrane Central databases from inception to May 2020. A random effects model meta-analysis was conducted and the I² statistic was used to assess for heterogeneity.

RESULTS

Four studies comprising 377 patients (PRP-HA: 193, HA: 184) with knee OA ranging from I-IV Kellgren-Lawrence grading scale were included. The final follow-up was 12 months in 3 studies and 6 months in 1 study. Patients who received PRP combined with HA had significantly greater improvements compared with those injected with HA alone in terms of visual analog scale scores at 3-month (standardized mean difference [SMD] 1.13; 95% confidence interval [CI] 0.56-1.70; I² = 56.7%; P < .001), 6-month (SMD 1.08; 95% CI 0.54-1.62; I² = 67.9%; P < .001), and 12-month (SMD 1.13; 95% CI 0.74-1.52; I² = 0.0%; P < .001) and 12-month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical functioning (SMD 0.91; 95% CI 0.65-1.17; I² = 0.0%; P < .001) and 12-month WOMAC stiffness (SMD 1.09; 95% CI 0.80-1.38; I² = 0.0%; P < .001) scores. No difference was identified in terms of 12-month WOMAC pain score (SMD 0.36; 95% CI -0.19 to 0.91; I² = 74.1%; P = .195).

CONCLUSIONS

Symptomatic patients with knee OA who were injected with a combination of PRP and HA demonstrated greater improvement in pain and function compared with patients who received HA injections only, as assessed by 3-, 6-, and 12-month visual analog scale scores and 12-month WOMAC physical function and stiffness scores. This study provides encouraging evidence for the use of the combined PRP-HA injections in the management of symptomatic patients with knee OA.

LEVEL OF EVIDENCE

III (meta-analysis of randomized and non-randomized comparative trials).

The intra-articular administration of triamcinolone hexacetonide in the treatment of osteoarthritis. Its effects in a naturally occurring canine osteoarthritis model

OBJECTIVE

To evaluate the effect of an intra-articular (IA) administration of triamcinolone hexacetonide, compared with saline.

PATIENTS AND METHODS

Forty (N = 40) hip joints were randomly assigned to a treatment group (THG, n = 20, receiving IA triamcinolone hexacetonide) and a control group (CG, n = 20, receiving IA saline). On treatment day (T0), and at 8, 15, 30, 90 and 180 days post-treatment, weight distribution, joint range of motion, thigh girth, digital thermography, radiographic signs, synovial fluid interleukin-1 and C-reactive protein levels were evaluated. Data from four Clinical Metrology Instruments was also gathered. Results were compared Repeated Measures ANOVA, with a Huynh-Feldt correction, Paired Samples T-Test or Wilcoxon Signed Ranks Test. A Kaplan-Meier test was performed to compare both groups, with p<0.05.

RESULTS

Joints were graded as mild (65%), moderate (20%) and severe (15%). Patients of both sexes, with a mean age of 6.5±2.4 years and bodyweight of 26.7±5.2kg, were included. No differences were found between groups at T0. Comparing THG to CG, weight distribution showed significant improvements in THG from 8 (p = 0.05) up to 90 days (p = 0.01). THG showed lower values during thermographic evaluation in the Lt view (p<0.01). Pain and function scores also improved from 30 to 180 days. Increasing body weight, age, and presence of caudolateral curvilinear osteophyte corresponded to worse response to treatment. Results of the Kaplan Meier test showed significant differences between groups, with THG performing better considering several evaluations and scores.

CONCLUSION

THG recorded significant improvements in weight-bearing and in with the considered CMIs, particularly pain scores. Lower thermographic values were registered in THG up to the last evaluation day. Age, sex, and radiographic findings did significantly influenced response to treatment.

Hyaluronic acid and platelet-rich plasma for the management of knee osteoarthritis

PURPOSE

Symptomatic knee osteoarthritis (OA) remains a substantial cause of pain and disability worldwide and effective management in young patients without indications for total knee arthroplasty remains challenging. Intra-articular injections represent a viable option in the non-operative treatment of knee OA. Hyaluronic acid (HA) and platelet-rich plasma (PRP) are two commonly utilized intra-articular treatment modalities that are of particular clinical interest in the current literature. The purpose of this manuscript is to provide a concise review of the current literature on the use of HA, PRP, and HA-PRP conjugates for the treatment of symptomatic knee OA.

METHODS

A review of the literature utilizing PubMed, OVID/Medline, and Cochrane databases on basic science and clinical literature pertaining to preparation, composition, and outcomes of HA, PRP, and HA-PRP conjugates in patients with symptomatic knee OA.

RESULTS

Both HA and PRP have been shown to be efficacious for the treatment of symptomatic knee OA, with HA injections providing limited short-term improvement, while PRP may provide greater therapeutic relief, particularly with the use of leukocyte-poor (LP-PRP) formulations. Despite limited data, the combination of different formulations of HA-PRP conjugates may provide a synergistic effect, resulting in a clinically significant improvement in both pain and function.

CONCLUSION

In patients with symptomatic knee OA, intra-articular HA and PRP provide short-term improvement in pain and function, while the efficacy of HA-PRP conjugates warrants further study.

[Budget impact analysis of viscosupplementation for non-surgical treatment of knee osteoarthritis]

Knee osteoarthritis affects 3.8% of the world population and manifests as pain, edema, stiffness, and reduced joint function, impacting the patient's quality of life. Treatment consists of the pharmacological, non-pharmacological, and surgical modalities. Viscosupplementation (intraarticular hyaluronate) has been proposed to relieve symptoms and potentially postpone surgery. This study estimated the budget impact of the association of this drug and non-surgical treatment (standard treatment) from the perspective of the Brazilian Unified National Health System. Based on the assumption that 5% of patients proceed to treatment and on the direct costs of the pharmacological and non-pharmacological modalities, the authors calculated the reference and alternative scenarios that compared the different treatment options in a three-year timeline. The principal analysis estimated an incremental budget impact of approximately BRL 126 million (U$ 32 million) for one vial of hyaluronate a year and BRL 252 million (USD 64 million) for two vials a year. Diacerein, an oral chondroprotector, assessed as an alternative, showed a budget impact of BRL 334 million (USD 86 million) in relation to standard treatment, representing a 24% cost increase compared to two vials a year of hyaluronate, making it less economically advantageous. Viscosupplementation can provide better quality of life for patients, reduce costs for the health system, and optimize the flow of care in health services. The estimates presented in this study can assist administrators in the best use of resources and thus in decision-making on the technology's incorporation.

Hyaluronic Acid: Molecular Mechanisms and Therapeutic Trajectory

Hyaluronic acid (also known as hyaluronan or hyaluronate) is naturally found in many tissues and fluids, but more abundantly in articular cartilage and synovial fluid (SF). Hyaluronic acid (HA) content varies widely in different joints and species. HA is a non-sulfated, naturally occurring non-protein glycosaminoglycan (GAG), with distinct physico-chemical properties, produced by synoviocytes, fibroblasts, and chondrocytes. HA has an important role in the biomechanics of normal SF, where it is partially responsible for lubrication and viscoelasticity of the SF. The concentration of HA and its molecular weight (MW) decline as osteoarthritis (OA) progresses with aging. For that reason, HA has been used for more than four decades in the treatment of OA in dogs, horses and humans. HA produces anti-arthritic effects via multiple mechanisms involving receptors, enzymes and other metabolic pathways. HA is also used in the treatment of ophthalmic, dermal, burns, wound repair, and other health conditions. The MW of HA appears to play a critical role in the formulation of the products used in the treatment of diseases. This review provides a mechanism-based rationale for the use of HA in some disease conditions with special reference to OA.

Hyaluronic Acid Combined with Serum Rich in Growth Factors in Corneal Epithelial Defects

The aim of this study is to assess if an adhesive biopolymer, sodium hyaluronate (NaHA), has synergistic effects with s-PRGF (a serum derived from plasma rich in growth factors and a blood derivative that has already shown efficacy in corneal epithelial wound healing), to reduce time of healing or posology. In vitro proliferation and migration studies, both in human corneal epithelial (HCE) cells and in rabbit primary corneal epithelial (RPCE) cultures, were carried out. In addition, we performed studies of corneal wound healing in vivo in rabbits treated with s-PRGF, NaHA, or the combination of both. We performed immunohistochemistry techniques (CK3, CK15, Ki67, ß4 integrin, ZO-1, α-SMA) in rabbit corneas 7 and 30 days after a surgically induced epithelial defect. In vitro results show that the combination of NaHA and s-PRGF offers the worst proliferation rates in both HCE and RPCE cells. Addition of NaHA to s-PRGF diminishes the re-epithelializing capability of s-PRGF. In vivo, all treatments, given twice a day, showed equivalent efficacy in corneal epithelial healing. We conclude that the combined use of s-PRGF and HaNA as an adhesive biopolymer does not improve the efficacy of s-PRGF alone in the wound healing of corneal epithelial defects.

Corticosteroids and Hyaluronic Acid Injections

Osteoarthritis is a common condition that affects many individuals resulting in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment. Studies have shown that they provide short-term pain improvement and can be used for osteoarthritis flares. Hyaluronic acid injections have extensively been studied in knee osteoarthritis but to a lesser degree in other joints. Despite some debate between societies, a large number of recent studies have shown hyaluronic acid to be a viable treatment option showing longer-term improvement in both pain and function.

Cost Effectiveness of Intra-Articular Hyaluronic Acid and Disease-Modifying Drugs in Knee Osteoarthritis

BACKGROUND

The place of disease-modifying osteoarthritis drugs (DMOADs) and intra-articular hyaluronic acid (IAHA) in the therapeutic arsenal for knee osteoarthritis (OA) remains uncertain. Indeed, these treatments have demonstrated symptomatic efficacy but no efficacy for disease modification.

OBJECTIVE

This report reviews the cost effectiveness of IAHA and DMOADs used in the treatment of knee OA.

METHODS

A systematic literature search of the MEDLINE, Scopus, EMBASE and Cochrane databases was performed independently by two rheumatologists who used the same predefined eligibility criteria to identify relevant articles. Papers without abstracts and in languages other than English or French were excluded. Extracted costs were annualised and converted to 2015 euros (€) using the Consumer Price Index of the relevant countries and the 2013 Purchasing Power Parities between these countries and the European Union average.

RESULTS

A total of 95 abstracts were selected, and 13 articles were considered for the review: nine articles on IAHA and four on DMOADs. Only one article directly compared different IAHA compounds. Articles showed substantial heterogeneity in methodological approaches. The incremental cost-effectiveness ratios (ICERs) ranged from €4000 to €57,550 and from €240 to €53,225 per quality-adjusted life-year (QALY) gained for DMOADs and IAHA, respectively.

CONCLUSIONS

This review highlights substantial heterogeneity between studies, ranging from a cost saving (or dominating) position to very high ICERs, far above the acceptability threshold of €50,000/QALY. Additional research is needed to determine reliable and robust ICER estimates for knee OA therapies.

A synthetic polymeric biolubricant imparts chondroprotection in a rat meniscal tear model

Intra-articular injection of hyaluronic acid (HA) is used to treat osteoarthritis (OA) as a viscosupplement, yet it only provides short-term benefit because HA is cleaved by hyaluronidase and cleared out of the joint after several days. Therefore, we developed a new polymer biolubricant based on poly-oxanorbornane carboxylate to enhance joint lubrication for a prolonged time. Rheological and biotribological studies of the biolubricant reveal viscoelastic properties and coefficient of friction equivalent and superior to that of healthy synovial fluid, respectively. Furthermore, in an ex vivo bovine cartilage plug model, the biolubricant exhibits superior long-term reduction of friction and wear prevention compared to saline and healthy synovial fluid. ISO 10993 biocompatibility tests demonstrate that the biolubricant polymer is non-toxic. In an in vivo rat medial meniscal tear OA model, where the performance of the leading HA viscosupplement (Synvisc-one®) is comparable to the saline control, treatment with the biolubricant affords significant chondroprotection compared to the saline control.

Intra-articular hyaluronic acid in the treatment of knee osteoarthritis: a Canadian evidence-based perspective

Osteoarthritis (OA) is a chronic condition characterized by a loss of joint cartilage and is a major cause of disability in Canada, with an estimated CN$195 billion annual cost. Knee OA leads to persistent pain and loss of function, and treatment goals primarily focus on symptom relief and retention of function. Intra-articular hyaluronic acid (IAHA) has therapeutic benefits, and numerous recently published meta-analyses (MAs) and commentaries have highlighted new evidence on the role of IAHA therapy for knee OA. A diverse, multidisciplinary group of specialists met independently in closed sessions to review findings from eight MAs with literature search end dates no earlier than 2012 to address controversies surrounding IAHA therapy for mild-to-moderate knee OA within the Canadian treatment context. Outcomes from a total of eight MAs were reviewed, and consistent and statistically significant improvements in pain, function and stiffness up to 26 weeks were found with IAHA therapy compared with IA placebo or controls, regardless of MA size or trial quality. These findings are in line with those of a Cochrane review, another recent systematic review and patient satisfaction survey. Overall, three MAs reported outcomes based on molecular weight (MW), with the two reporting effect sizes showing significantly improved pain outcomes for higher compared with lower MW HAs. Recent evidence suggests that HA therapy is well tolerated with no increased risk of serious adverse events compared with placebo and the full therapeutic effect of IAHA therapy appears to have considerable clinical importance, consisting of the combined IA placebo and HA therapeutic effects. IAHA therapy is a well-tolerated and effective option for patients with mild-to-moderate knee OA failing first-line pharmacological therapy.

Are We Using Slow-Acting Symptomatic Chondroprotective Drugs Conscious Enough?

Background:

Osteochondral injuries constitute an entity that is widespread and can be seen in patients of all ages. Actual treatment modalities aim to relieve pain, obtain full range of movement of the joint, and improve the quality of life. There are many slow-acting chondroprotective agents prevalently used in the United States that are classified as nutritional support but not as medicines . This study presents the importance of clinical adverse effect profiles as well as the pharmacological mechanism of action and application of combinations of drugs that are widely prescribed and not subjected to control.

Methods:

Electronic databases were searched with keywords about the chondroprotective drugs without any language restriction. Evaluations of the descriptive statistics were represented via Microsoft Office Excel 2010 lists in the form of a mean±standard deviation or frequency (%). The first evaluation showed that 1502 studies were potentially relevant. Following exclusion of the 1277 studies which were not clinical, full versions of the remaining 225 studies were subjected to further evaluation. No controlled, blinded, randomized and/or comparative studies met the inclusion criteria of the study, and no studies evaluated the comparative clinical results of the hyaluronan of different molecular weights.

Results:

The findings of this study concluded that especially when prescribing drugs with ingredients like GS and CS, many patients’ pre-existing conditions must be considered, such as whether the patient has a glucose intolerance or not. Additionally, mineral toxication should be considered since the drugs contain minerals, and after the application of injected hyaluronan, complications should be considered.

Conclusion:

Clinical, controlled and comparative studies about the use of chondroprotective drugs must be performed to define the benefits of these drugs, if any, in order to determine the most suitable time for operative intervention.

Intra articular hyaluronic acid in the management of knee osteoarthritis: Pharmaco-economic study from the perspective of the national health insurance system

Introduction

Pharmaco-economic data on the management of knee osteoarthritis (OA) with intra articular hyaluronic acid (IA HA) viscosupplementation is limited. We contrasted IA HA with non-steroidal anti-inflammatory drugs (NSAIDs).

Methods

Observational, prospective and multicenter study comparing treatments of knee OA costs and efficacy with either NSAIDs alone, or hyaluronic acid (Arthrum H 2%^®), during a 6-month follow-up period. The investigators were pharmacists who recorded data on disease, drug consumption and healthcare circuit. Retrospectively, the 6-month period preceding inclusion was also studied, to ensure the comparability of groups.

Results

199 patients were analyzed in a NSAIDs group and 202 in an IA HA group. Any of the WOMAC sub-scores and the EQ-5D Quality of Life index were significantly improved in the IA HA group (p<0.0001) at 3 and 6 months. Clinical results were therefore in favor of the IA HA group. The total drug expenses per 6-month period were comparable before and after inclusion, €96 and €98 for NSAIDs group vs €94 and €101 for IA HA group, which indicates no evidence of additional cost from IA HA. For the active part of the population, the incidence of sick leave was lower in the IA HA group, indicating a better maintenance of patient activity. The overall expense on 12 months (6 months before and 6 months after inclusion) for the national health insurance system was comparable for NSAIDs and IA HA groups: €528 and €526, respectively. The number of patients taking NSAIDs significantly decreased in IA HA group (from 100% at inclusion to 66% at 1–3 months and 44% at 4–6 months), but remained unchanged (100%) during the follow-up period, in NSAIDs group.

Conclusion

Treatment with IA HA did not generate additional cost for the national health insurance and was associated with a functional improvement of knee osteoarthritis and Quality of Life. The cost-utility analysis was in favor of IA HA, with a gain of QALY equivalent to half a month, after the 6-month follow-up period comparing both treatments. The NSAIDs consumption was decreased in the IA HA group, resulting in an improved estimated benefit/risk ratio.

Efficacy of glucosamine plus diacerein versus monotherapy of glucosamine: a double-blind, parallel randomized clinical trial

Background

Patented crystalline glucosamine sulfate (pCGS) and diacerein monotherapy have been recommended for treatment of mild to moderate osteoarthritis (OA), but evidence of efficacy for combined treatments is lacking. Therefore, the aim of this study was to compare clinical outcomes (i.e., pain and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] score) at 6 months as well as the safety profile of treatment with combined pCGS and diacerein versus pCGS alone.

Methods

A double-blind, parallel randomized controlled superiority trial was conducted between August 2013 and August 2014 at Ramathibodi Hospital, Bangkok, Thailand. A total of 148 patients (74 patients in each group) was randomly allocated to receive pCGS plus diacerein or pCGS plus placebo daily. Adult patients with OA were eligible if they had a Kellgren-Lawrence grade of 2–3. The primary outcomes were visual analogue scale score (VAS) for pain and WOMAC subscores measured at 24 weeks after receiving treatment, using the intention-to-treat principle (nonresponder imputation).

Results

Among the 148 patients in the study, mean age and body mass index were 60 years and 28.1 kg/m², respectively. Mean VAS and minimal joint space width at baseline were 5.1 and 2.5 mm, respectively. The mean VAS values measured at 24 weeks were 2.97 and 2.88 in the pCGS plus diacerein and pCGS plus placebo groups, respectively. The estimated mean difference was 0.09 (95 % CI −0.75 to 0.94), which was not statistically significant (P = 0.710). In addition, the mean WOMAC total, pain, function, and stiffness scores for both groups were not significantly different, with corresponding means of 48.59, 12.02, 32.74, and 3.85 for the pCGS plus diacerein group and 48.69, 11.76, 32.47, and 4.16 for the pCGS plus placebo group. The risk of diarrhea and dyspepsia was very similar between the two groups, with risk ratios of 1.03 (95 % CI 0.56–1.89) and 0.91 (95 % CI 0.43–1.92), respectively.

Conclusions

This study did not demonstrate that coadministration of diacerein with pCGS improves pain and WOMAC score compared with pCGS monotherapy in patients with mild to moderate OA of the knee.

Trial registration

ClinicalTrials.gov identifier: NCT01906801. Registered on 20 July 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1124-9) contains supplementary material, which is available to authorized users.

Hyaluronic acid in the management of osteoarthritis: injection therapies innovations

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by pain and progressive functional limitation. Viscosupplementation with intra-articular (IA) hyaluronic acid (HA) could be a treatment option in OA, however recommendations made in different international guidelines for the non-surgical management of OA are not always concordant with regard to the role of IA injection therapies. Results from a recent Italian Consensus Conference underline how IA-HA to treat OA represents a widely used therapy in Italy. Specifically high molecular weight HA, cross-linked HA, and mobile reticulum HA are considered very useful to treat the OA joints from a great number of expert in Italy. These kinds of HA could reduce the NSAIDs intake, furthermore high-molecular weight and mobile reticulum HA are considered to be able to delay or avoid a joint prosthetic implant. This mini review highlights the results obtained from the Italian Consensus Conference "Appropriateness of clinical and organizational criteria for intra-articular injection therapies in osteoarthritis" and give further indication about innovation in IA-HA therapies.

Caution should be used in long-term treatment with oral compounds of hyaluronic acid in patients with a history of cancer

Intra-articular administration of hyaluronic acid is a valuable therapeutic tool for the management of patients with osteoarthritis. However, in recent years numerous formulations containing hyaluronic acid administrable by oral route have entered the market. Even if there are some data in the literature that have shown their effectiveness, systemic administration may expose a greater risk in certain situations. In fact, although hyaluronic acid is not considered a drug it is certain that it can interact with specific receptors and promote cell proliferation. This interaction may be potentially hazardous in cancer patients for which these oral formulations should be contraindicated.

[Injection treatment with hyaluronic acid]

This article presents the spectrum of indications for the use of hyaluronic acid (HA) based on the recommendations of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), the Osteoarthritis Research Society International (OARSI), the International Institute for Health and Clinical Excellence (NICE) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) taking the reality of patient care in Europe into account.

Effectiveness and utility of hyaluronic acid in osteoarthritis

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by pain and progressive functional limitation. Viscosupplementation with intra-articular hyaluronic acid is a treatment option in knee OA that is included in the professional guidelines for treatment of this joint disease, but potentially should apply to all synovial joints in order to reduce pain and improve joint lubrication. Exogenous HA can enhance chondrocyte HA synthesis, prevent the degradation of cartilage and promote its regeneration. Moreover it can reduce the production of proinflammatory mediators and matrix metalloproteinases involved in OA pathogenesis. This mini review highlights the evidence of hyaluronic acid in reducing osteoarthritis symptoms and structural damage, as well as its ability to delay prosthetic surgery. Viscosupplementation should be considered as a long-term therapy.

Cost-effectiveness Analysis of Viscosupplementation versus Conventional Supportive Therapy for Knee Osteoarthritis in Colombia

BACKGROUND

Treatment goals for knee osteoarthritis (OA) include preservation of mobility, control of pain, and delaying total knee replacement (TKR).

OBJECTIVE

To estimate the cost-effectiveness of viscosupplementation (hylan G-F 20) alone compared with conventional supportive therapy (CST) in the treatment of knee OA in Colombia.

METHODS

Microsimulation in patients with knee OA, modeling of clinical outcomes (disease progression, symptom improvement, TKR), and estimation of associated costs were performed (drugs, diagnostic tests, procedures, and hospitalizations). The probabilities for disease progression and clinical events were correlated with patients' characteristics. Clinical outcome information was obtained from the literature. The costs were drawn from institutional databases from health maintenance organizations and the Colombian standard tariffs handbook (ISS 2001. Agreement No. 256 of 2001. Tariffs for the health promoter Social Security EPS-ISS. Social Insurance Board of Directors. December 19, 2001). Sensitivity analyses were performed for costs and transition probabilities.

RESULTS

Monte-Carlo simulation for 1000 patients with knee OA showed that viscosupplementation with hylan G-F 20 delayed the occurrence of TKR by 3 years compared with CST. Western Ontario and McMaster Universities Arthritis Index scores indicate improvement in symptoms and function with hylan G-F 20. The incremental cost-effectiveness ratio for viscosupplementation is dominant, with reduction of US $576 in treatment cost in favor of hylan G-F 20, with more cost-effectiveness per quality-adjusted life-year during the first 10 years of treatment compared with CST.

CONCLUSIONS

The results of mathematical simulation indicate that in comparison to conventional support therapies, viscosupplementation with hylan G-F 20 improved disease symptoms, joint function, and quality of life, reduced direct treatment costs, delayed TKR by 3 years, and was cost-effective in Colombia.

Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis

Viscosupplementation (VS) with hyaluronic acid is currently used by physicians to treat osteoarthritis. However, many aspects of this treatment remain questionable and subject of controversy. A group of 8 experts in this field, from European countries, met to debate on 24 statements previously listed by the group members. Based on an extensive research of the literature and expert opinion, a consensus position has been proposed for each statement. Agreement was achieved on some recommendations. In particular, the expert achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA; VS should not be used only in patients who have failed to respond adequately to analgesics and NSAIDs; VS is a "positive" indication but not a "lack of anything better" indication; the dosing regimen must be supported by evidence-based medicine; cross-linking is a proven means for prolonging IA residence time of HA; the best approach to inject accurately knee joint is the lateral mid-patellar one; when VS is performed under fluoroscopy, the amount of radiopaque contrast agent must be as low as possible to avoid viscosupplement dilution. These clear recommendations have been established to help practitioners in the use of viscosupplementation.

Comparison of two hyaluronic acid formulations for safety and efficacy (CHASE) study in knee osteoarthritis: a multicenter, randomized, double-blind, 26-week non-inferiority trial comparing Durolane to Artz

INTRODUCTION

Intra-articular injection of hyaluronic acid (HA) is often used as therapy for knee osteoarthritis because it is less expensive and less aggressive than total knee replacement. Therefore, it is important to document whether HA is safe and efficacious. We tested whether single and multiple injection viscosupplementation with HA is associated with clinically meaningful pain relief in a new randomized clinical trial (RCT). Our objective was to compare safety and efficacy of intra-articular HA in two formulations: one 3.0 ml injection of Durolane versus five 2.5 ml injections of Artz for the treatment of knee osteoarthritis pain.

METHODS

Patients (N=349) from the People's Republic of China were randomized to treatment (Durolane=175, Artz=174). The Durolane group received a 3.0 ml injection at week 0 (baseline), with sham skin punctures at weeks 1, 2, 3, and 4. The Artz group received one 2.5 ml injection at each of the same time points. The primary assessment tool was the Likert-type Western Ontario and McMaster University (WOMAC) pain scale at weeks 0, 6, 10, 14, 18, and 26. Secondary assessments were WOMAC physical function, knee stiffness, and global self-assessment, at identical time points. Statistically-controlled analyses were non-inferiority of Durolane over 18, then over 26 weeks, with a priori non-inferiority defined as 8% of the relevant scale. Acetaminophen was permitted as rescue analgesia and all adverse events (AEs) were recorded.

RESULTS

Overall study retention was excellent; 332 patients (95.1%) completed 18 weeks and 319 (91.4%) completed 26 weeks, with no significant retention difference between treatment arms. All variables met non-inferiority criteria over 18 and 26 weeks. Efficacy response in both arms was >90%. Treatment-related AEs were 9.8% (17/174) for Artz and 13.1% (23/175) for Durolane.

CONCLUSIONS

A single injection of Durolane is non-inferior to 5 injections of Artz over 18 and 26 weeks for pain, physical function, global self-assessment, and knee stiffness. Both treatments were efficacious, safe, and well tolerated.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01295580 . Registered 11 February 2011.

Sorbitol-modified hyaluronic acid reduces oxidative stress, apoptosis and mediators of inflammation and catabolism in human osteoarthritic chondrocytes

OBJECTIVE AND DESIGN

Our study was designed to elucidate the precise molecular mechanisms by which sorbitol-modified hyaluronic acid (HA/sorbitol) exerts beneficial effects in osteoarthritis (OA).

METHODS

Human OA chondrocytes were treated with increasing doses of HA/sorbitol ± anti-CD44 antibody or with sorbitol alone and thereafter with or without interleukin-1beta (IL-1β) or hydrogen peroxide (H2O2). Signal transduction pathways and parameters related to oxidative stress, apoptosis, inflammation, and catabolism were investigated.

RESULTS

HA/sorbitol prevented IL-1β-induced oxidative stress, as measured by reactive oxygen species, p47-NADPH oxidase phosphorylation, 4-hydroxynonenal (HNE) production and HNE-metabolizing glutathione-S-transferase A4-4 expression. Moreover, HA/sorbitol stifled IL-1β-induced metalloproteinase-13, nitric oxide (NO) and prostaglandin E2 release as well as inducible NO synthase expression. Study of the apoptosis process revealed that this gel significantly attenuated cell death, caspase-3 activation and DNA fragmentation elicited by exposure to a cytotoxic H2O2 dose. Examination of signaling pathway components disclosed that HA/sorbitol prevented IL-1β-induced p38 mitogen-activated protein kinase and nuclear factor-kappa B activation, but not that of extracellular signal-regulated kinases 1 and 2. Interestingly, the antioxidant as well as the anti-inflammatory and anti-catabolic effects of HA/sorbitol were attributed to sorbitol and HA, respectively.

CONCLUSIONS

Altogether, our findings support a beneficial effect of HA/sorbitol in OA through the restoration of redox status and reduction of apoptosis, inflammation and catabolism involved in cartilage damage.

Cost-effectiveness analysis of intra-articular injections of a high molecular weight bioengineered hyaluronic acid for the treatment of osteoarthritis knee pain

OBJECTIVE

To determine the cost-effectiveness of bioengineered hyaluronic acid (BioHA, 1% sodium hyaluronate) intra-articular injections in treating osteoarthritis knee pain in poor responders to conventional care (CC) including non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics.

METHODS

Two decision analytic models compared BioHA treatment with either continuation of patient's baseline CC with no assumption of disease progression (Model 1), or CC including escalating care costs due to disease progression (NSAIDs and analgesics, corticosteroid injections, and surgery; Model 2). Analyses were based on patients who received two courses of 3-weekly intra-articular BioHA (26-week FLEXX Trial + 26-week Extension Study). BioHA group costs included fees for physician assessment and injection regimen, plus half of CC costs. Cost-effectiveness ratios were expressed as averages and incremental costs per QALY. One-way sensitivity analyses used the 95% confidence interval (CI) of QALYs gained in BioHA-treated patients, and ±20% of BioHA treatment and CC costs. Probabilistic sensitivity analyses were performed for Model 2.

RESULTS

For 214 BioHA patients, the average utility gain was 0.163 QALYs (95% CI = -0.162 to 0.488) over 52 weeks. Model 1 treatment costs were $3469 and $4562 for the BioHA and CC groups, respectively; sensitivity analyses showed BioHA to be the dominant treatment strategy, except when at the lower end of the 95% CI. Model 2 annual treatment costs per QALY gained were $1446 and $516 for the BioHA and CC groups, respectively. Using CC as baseline strategy, the incremental cost-effectiveness ratio (ICER) of BioHA was $38,741/QALY gained, and was sensitive to response rates in either the BioHA or CC groups.

CONCLUSION

BioHA is less costly and more effective than CC with NSAIDs and analgesics, and is the dominant treatment strategy. Compared with escalating CC, the $38,741/QALY ICER of BioHA remains within the $50,000 per QALY willingness-to-pay threshold to adopt a new technology.

Functional impairment in obesity: a focus on knee and back pain

SUMMARY Cross-sectional and longitudinal evidence strongly indicate that obesity is related to physical impairment and joint pain, particularly in the lumbar spine, sacroiliac and knee joints. What is most disturbing is that obese children under 15 years are now reporting joint pain and cannot perform functional tasks as well as their nonobese counterparts. As the prevalence of obesity rises, so do the rates of musculoskeletal disease and physical dysfunction. Functional tasks that involve supporting or transferring body weight are typically painful and difficult to perform. Of most concern is that some of these tasks are simply impossible depending on the severity of obesity. As a consequence, the individual's quality of life suffers. A BMI of 35 kg/m(2) is emerging as the threshold at which functional impairment rates rise dramatically. To restore functional independence and optimize functional gains over the long term, a combination of treatments for the obese patient with joint pain may be effective. The initial use of physical therapy, pain medications or joint viscosupplementation, coupled with diet, exercise, or bariatric surgery are options for weight loss and reduction of pain symptoms. Irrespective of age, weight loss can reduce or eliminate joint pain. As body weight is reduced, so should the reliance on medication with a concomitant improvement in functional mobility.

Knee osteoarthritis: hyaluronic acid, platelet-rich plasma or both in association?

INTRODUCTION

Bidirectional interactions between cells and fluidic surroundings regulate cellular functions and maintain tissue or organ architecture. Accordingly, the synovial fluid is the primary source of environmental signals and determines to a great extent the molecular interactions within the joint capsule, both in homeostasis and pathology.

AREAS COVERED

We provided an update on hyaluronic acid (HA) and platelet-rich plasma (PRP) concepts necessary to build the rationale for creating a combined treatment. The information is based on a PubMed search using the terms 'platelet-rich plasma', 'hyaluronic acid', 'knee pathology', 'knee osteoarthritis' (OA).

EXPERT OPINION

In OA, a deleterious fluidic microenvironment is established, with presence of HA fragments, catabolic enzymes and inflammatory molecules. The central concept underlying intra-articular injection is to modify deleterious fluidic microenvironments. PRP administration has shown pain remission and function improvement, but less than half of the patients showed clinically significant improvement. PRP exceeds HA, the comparator used in PRP clinical trials, albeit both HA and PRP alleviate symptoms in mild-to-moderate OA patients. Combining PRP and HA may benefit from their dissimilar biological mechanisms and help in controlling delivery and presentation of signaling molecules. Three armed randomized studies, using both HA and PRP as comparators, will provide information about the impact of this approach.

Safety and Tolerability of Intra-Articular Hyaluronic Acid Injection (Sinovial®) in Experimental and Clinical Practice

Osteoarthritis (OA) requires long-term treatment, therefore, tolerability is a key factor in treatment choice. Hyaluronic acid (HA), a glycosaminoglycan with viscoelastic properties, a major component of synovial fluid and the extracellular matrix of the joint cartilage, plays key roles in synovial fluid viscosity and maintaining normal cartilage. Viscosupplementation is an intra-articular (IA) injection of exogenous HA in an effort to delay joint mobility loss. Commercially available viscosupplementation includes HA of different average molecular weight (MW), concentration and origins, with varying tolerability. This review describes the tolerability and safety profile of Sinovial® in knee and hip OA. A literature search of PubMed using the search queries [Sinovial® OR hyaluronic acid OR hyaluronan] and [intra-articular OR osteoarthritis] was performed using terms as medical subject headings and free text searches. Studies were selected manually for inclusion in this review. Sinovial® is a low-medium MW HA of non-avian origin, produced by biofermentation to ensure the product is pure and free of allergenic animal proteins. We analyzed data regarding the tolerability of Sinovial® in OA patients. This formulation has a favorable tolerability profile; no systemic reactions have been reported and most adverse events (AEs) are mild, transient and easily managed local injection site reactions. Reactions — pain and burning at the injection site - are typical of IA injections. AEs with Sinovial® used in the hip are similar to knee OA.

Early decrease of serum biomarkers of type II collagen degradation (Coll2-1) and joint inflammation (Coll2-1 NO₂ ) by hyaluronic acid intra-articular injections in patients with knee osteoarthritis: a research study part of the Biovisco study

To measure the evolution of the serum levels of specific Osteoarthritis (OA) biomarker, Coll2-1 and Coll2-1 NO₂ in knee osteoarthritic patients after viscosupplementation (VS). Fifty-one patients with unilateral symptomatic knee were recruited for this prospective open label study. They received three intra-articular injections of 2 ml of hyaluronic acid (Hylan GF-20) and were followed for 3 months. Walking pain was evaluated and serum samples were taken at each visit. Coll2-1 and Coll2-1 NO₂ were measured in the serum using specific immunoassays. Variations over time of each parameter and predictive factor of response were studied. Forty-five patients were analyzed. The serum concentrations of Coll2-1 and Coll2-1 NO₂ were significantly higher in KL III/IV patients compared to KL I/II patients at baseline and decreased systematically over time after VS. Its effect was ever more pronounced in patients with KL III/IV. The serum concentration of Coll2-1 was significantly lower at baseline in responders than in non-responders. This study suggests a rapid slowdown of type II collagen degradation and joint inflammation after VS with Hylan G-20 and gives additional information for the validation of accurate biomarkers for OA. The serum level of Coll2-1 appeared to be a predictive factor for response to treatment.

Diminished cartilage-lubricating ability of human osteoarthritic synovial fluid deficient in proteoglycan 4: Restoration through proteoglycan 4 supplementation

OBJECTIVE

The purposes of this study were 1) to quantify the proteoglycan 4 (PRG4) and hyaluronan (HA) content in synovial fluid (SF) from normal donors and from patients with chronic osteoarthritis (OA) and 2) to assess the cartilage boundary-lubricating ability of PRG4-deficient OA SF as compared to that of normal SF, with and without supplementation with PRG4 and/or HA.

METHODS

OA SF was aspirated from the knee joints of patients with symptomatic chronic knee OA prior to therapeutic injection. PRG4 concentrations were measured using a custom sandwich enzyme-linked immunosorbent assay (ELISA), and HA concentrations were measured using a commercially available ELISA. The molecular weight distribution of HA was measured by agarose gel electrophoresis. The cartilage boundary-lubricating ability of PRG4-deficient OA SF, PRG4-deficient OA SF supplemented with PRG4 and/or HA, and normal SF was assessed using a cartilage-on-cartilage friction test. Two friction coefficients (μ) were calculated: static (μ(static, Neq) ) and kinetic (<μ(kinetic, Neq) >) (where N(eq) represents equilibrium axial load and angle brackets indicate that the value is an average).

RESULTS

The mean ± SEM PRG4 concentration in normal SF was 287.1 ± 31.8 μg/ml. OA SF samples deficient in PRG4 (146.5 ± 28.2 μg/ml) as compared to normal were identified and selected for lubrication testing. The HA concentration in PRG4-deficient OA SF (mean ± SEM 0.73 ± 0.08 mg/ml) was not significantly different from that in normal SF (0.54 ± 0.09 mg/ml). In PRG4-deficient OA SF, the molecular weight distribution of HA was shifted toward the lower range. The cartilage boundary-lubricating ability of PRG4-deficient OA SF was significantly diminished as compared to normal (mean ± SEM <μ(kinetic, Neq) > = 0.043 ± 0.008 versus 0.025 ± 0.002; P < 0.05) and was restored when supplemented with PRG4 (<μ(kinetic, Neq) > = 0.023 ± 0.003; P < 0.05).

CONCLUSION

These results indicate that some OA SF may have decreased PRG4 levels and diminished cartilage boundary-lubricating ability as compared to normal SF and that PRG4 supplementation can restore normal cartilage boundary lubrication function to these OA SF.

Potential directions for drug development for osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a frustrating disease for both patient and physician because neither cause nor cure is known and there are currently no disease-modifying drugs.

OBJECTIVE

To review current therapeutic approaches as well as new findings regarding OA pathoetiology that could form the basis of future direction for the development of drugs to prevent or slow down disease progression.

METHODS

After reviewing disease progression in human OA, as demonstrated by histological analyses, the reasons for cartilage erosion are explored and possible therapeutic approaches are highlighted.

RESULTS/CONCLUSIONS

OA may be an epigenetic disease. This new concept can explain many aspects of the disease and provide reasons why therapeutic approaches until now have met with little success.

Hyaluronic acid induces activation of the κ-opioid receptor

INTRODUCTION

Nociceptive pain is one of the most common types of pain that originates from an injury involving nociceptors. Approximately 60% of the knee joint innervations are classified as nociceptive. The specific biological mechanism underlying the regulation of nociceptors is relevant for the treatment of symptoms affecting the knee joint. Intra-articular administration of exogenous hyaluronic acid (HA) in patients with osteoarthritis (OA) appears to be particularly effective in reducing pain and improving patient function.

METHODS

We performed an in vitro study conducted in CHO cells that expressed a panel of opioid receptors and in primary rat dorsal root ganglion (DRG) neurons to determine if HA induces the activation of opioid peptide receptors (OPr) using both aequorin and the fluorescent dye Fura-2/AM.

RESULTS

Selective agonists and antagonists for each OPr expressed on CHO cells were used to test the efficacy of our in vitro model followed by stimulation with HA. The results showed that HA induces stimulatory effects on the κ receptor (KOP). These effects of HA were also confirmed in rat DRG neurons, which express endogenously the OPr.

CONCLUSIONS

HA activates the KOP receptor in a concentration dependent manner, with a pEC(50) value of 7.57.

Effects of equine joint injury on boundary lubrication of articular cartilage by synovial fluid: role of hyaluronan

OBJECTIVE

To compare equine synovial fluid (SF) from injured and control joints for cartilage boundary lubrication function; concentrations of the putative boundary lubricant molecules hyaluronan (HA), proteoglycan 4 (PRG4), and surface-active phospholipids (SAPLs); relationships between lubrication function and composition; and lubrication restoration by addition of HA.

METHODS

Equine SF from normal joints, joints with acute injury, and joints with chronic injury were analyzed for boundary lubrication of normal articular cartilage (kinetic friction coefficient [μ(kinetic) ]). Equine SF samples were analyzed for HA, PRG4, and SAPL concentrations and HA molecular weight distribution. The effect of the addition of HA, of different concentrations and molecular weight, on the μ(kinetic) of equine SF samples from normal joints and joints with acute injury was determined.

RESULTS

The μ(kinetic) of equine SF from joints with acute injury (0.036) was higher (+39%) than that of equine SF from normal joints (0.026). Compared to normal equine SF, SF from joints with acute injury had a lower HA concentration (-30%) of lower molecular weight forms, higher PRG4 concentration (+83%), and higher SAPL concentration (+144%). Equine SF from joints with chronic injury had μ(kinetic) , PRG4, and SAPL characteristics intermediate to those of equine SF from joints with acute injury and normal equine SF. Regression analysis revealed that the μ(kinetic) value decreased with increasing HA concentration in equine SF. The friction-reducing properties of HA alone improved with increasing concentration and molecular weight. The addition of high molecular weight HA (4,000 kd) to equine SF from joints with acute injury reduced the μ(kinetic) to a value near that of normal equine SF.

CONCLUSION

In the acute postinjury stage, equine SF exhibits poor boundary lubrication properties, as indicated by a high μ(kinetic) . HA of diminished concentration and molecular weight may be the basis for this, and adding HA to deficient equine SF restored lubrication function.

The mid-term efficacy of intra-articular hyaluronic acid injections on joint structure: a nested case control study

OBJECTIVE

Intra-articular (IA) injection of hyaluronic acid (HA) has been shown to relieve osteoarthritis (OA)-related pain and improve joint structure within a 1-year period. We examined the mid-term (2-year) efficacy of IA-HA in Japanese subjects by using a large-scale population-based cohort of the Research on Osteoarthritis/Osteoporosis Against Disability study.

METHODS

We performed a nested case control study of 60 case control pairs matched for age (within 1 year), sex, Kellgren and Lawrence grade, and history of knee pain. The mean follow-up period after IA-HA series was 2.9 years in case patients. We examined the association of IA-HA with knee radiographic severity and knee pain. To estimate radiographic severity of OA, six distinct features--joint space area and the minimum joint space width at medial and lateral sides, osteophyte area, and tibiofemoral angle--were measured using a fully automatic computer-assisted program.

RESULTS

Comparison of the radiographic parameters between case patients and controls showed that the medial and lateral joint space areas were significantly bigger in case patients than in controls. After constructing a multivariate logistic regression model to examine the correlation of knee pain, IA-HA, and radiographic features, we found that unlike radiographic features, IA-HA was protectively associated with the presence of pain.

CONCLUSION

IA-HA might effectively improve joint structure and relieve pain in patients with knee OA.

Viscosupplementation with hylan g-f 20 in patients with osteoarthrosis of the knee

Viscosupplementation (VIS) is one of several treatment modalities for osteoarthritis of the knee. It is useful in the treatment of osteoarthritis when other methods of conservative care have failed and it may be a safer method of treatment than oral chemical therapy which can have significant side effects with even short-term usage. The biochemical effects of hyaluronic acid are incompletely understood, however there are several accepted modes of action which result in a positive clinical effect on the function of the knee joint. There is some evidence that hyaluronic acid preparations with a higher molecular weight may be more beneficial to the patient. It is commonly used after arthroscopic meniscectomy and or debridement of the knee in a patient with chondral disease. The clinical effects have been well documented in multiple studies in patients with mild to moderate osteoarthritis in study groups before or after arthroscopic surgery of the knee. Adverse events do occur and are easily treated with only rare case reports of systemic effects. Furthermore, there is some evidence that VIS can prolong the need for total knee arthroplasty in the older patient as well.

Early effect of hyaluronic acid intra-articular injections on serum and urine biomarkers in patients with knee osteoarthritis: An open-label observational prospective study

The aim of the study was to investigate the effect of hyaluronic acid (HA) intra articular injections (IA) on osteoarthritis (OA) biomarkers in patients with knee OA. Prospective open label study. Fifty-one patients with unilateral symptomatic K-OA received IA injections of 2mL of HA on days (D) 1, 7, 14 and were followed 3 months. At D-15 patients were examined and X-rays performed, to exclude patients with bilateral K-OA, or those with more than three symptomatic OA joints. From 15 days (D-15) before the first injection to D90 concomitant therapies were unchanged. Walking pain (WP) on VAS was obtained at each visit. Urine (U) and serum (S) samples were obtained at D-15, D1, D30, and D90. S-C2C, S-Cartilage oligomeric matrix protein, S-HA, S-CS 846 epitope, S-type II collagen propeptide, and U-type II collagen C telopeptide (U-CTX II/creatinin) were assayed. Predictive factors of response were analyzed using logistic regression. Correlations between variables were obtained using Spearman test. Forty-five patients were analyzed. Between D-15 and D1 there was no difference for any biomarkers At D1, WP (SD) was correlated with U-CTX II/creat (p = 0.006). Between D1 and D90: U-CTX II/creat decreased significantly. After adjustment for confounding variables there was a significant correlation between clinical response and U-CTX II/creat variation. U-CTX II and S-HA at baseline were independently predictive of clinical response. This study showed that 90 days after HA IA injections, U-CTX II levels significantly decrease compared to baseline, suggesting a slowdown of type II collagen degradation.

A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee

OBJECTIVE

The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee.

METHODS

Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

RESULTS

Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction ($17) in cost per patient per year, and a 58% ($224) reduction in cost per responder per year for a hospital outpatient (P < 0.001).

CONCLUSIONS

Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.