Image-guided steroid injections urged in hip OA.

AMSTERDAM -- Radiologically guided corticosteroid injections brought marked symptomatic improvement to patients with advanced hip osteoarthritis in a double-blind, placebo-controlled randomized trial, Dr. Walter P. Maksymowych reported at the annual European Congress of Rheumatology.

Many physicians perform these injections without imaging-guided assistance--and as a result, they often miss the mark, according to Dr. Maksymowych, professor of medicine at the University of Alberta, Edmonton. That's the likely explanation for the negative results of some previous studies of intraarticular steroid injections for hip osteoarthritis, he added.

Dr. Maksymowych and his colleague Dr. Robert Lambert, professor of radiology also at Alberta, reported on 52 patients who were randomized to fluoroscopically guided injections of 40 mg of triamcinolone hexacetonide or 2 mL of normal saline. All patients had hip osteoarthritis (OA) with marked structural joint damage on X-ray. All were experiencing high levels of pain and other symptoms that were no longer adequately relieved by NSAIDs and pain medications. Many were on the waiting list for hip replacement surgery.

The primary study end point was change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOM-AC) pain scores 2 months post treatment. Scores in the active-treatment group were reduced from a mean of 310 mm at baseline to 157 mm. The placebo group's scores remained unchanged. Results of all secondary end points were also significantly better in patients who received steroid injections (see chart).

Misconceptions regarding intraarticular steroid injections for OA abound among physicians and patients. Many physicians, overconfident in their manual skills, dismiss the need for imaging guidance of the needle--a big mistake, Dr. Maksymowych noted.

And many patients worry that repeated steroid injections into the hip may be harmful. However, Dr. Maksymowych stressed that there is no evidence that the injections induce structural joint damage or are otherwise harmful to patients.

"On the other hand, there's no evidence at this point in time that repeated corticosteroid injections prevent progression of joint damage," the rheumatologist added at the congress sponsored by the European League Against Rheumatism.

Both EULAR and the American College of Rheumatology endorse the use of corticosteroid injections as a key recommendation in the management of OA. But the guidelines also characterize the supporting evidence as weak, which was certainly the case up until this new randomized trial, he said. Some physicians have declined to offer steroid injections, despite the recommendations, because the practice was not backed by a solid evidence base. The procedure is likely to win converts because of these convincingly positive new data, Dr. Maksymowych predicted.

BY BRUCE JANCIN

Denver Bureau

Intraarticular Steroids Bring Big Improvement

                                    Steroid group   Placebo group

Patients with more than 50%
  improvement in WOMAC pain scores

at 1 month                          71%             14%
at 2 months                         61%             14%

Mean WOMAC stiffness
  scores (mm)
at baseline                         137             124
at 2 months                          76             135

Mean WOMAC stiffness
  scores (mm)
at baseline                         901             914
at 2 months                         502             897

Note: Based on a study of 52 patients.
Source: Dr. Maksymowych
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