Hormone intramuscular injection VS intra-articular injection, what should be the choice for patients with knee osteoarthritis?

*Only for medical professionals to read and refer to the two injection methods, are there any pros and cons? On April 5, 2022, JAMA Network Open published a study titled "Effect of Intramuscular vs Intra-articular Glucocorticoid Injection on Pain Among Adults With Knee Osteoarthritis"
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This article explores the clinical practical question of whether intramuscular (IM) glucocorticoids are noninferior to intra-articular (IA) glucocorticoids in reducing pain in patients with knee osteoarthritis (KOA)
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 Screenshot of the document "The Rheumatism and Immunity Channel of the Medical Community" specially invited Professor Xie Xi from the Second Xiangya Hospital of Central South University to share this research, bringing dry goods of clinical value to the readers
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 STUDY ABSTRACT Swipe up for background: IA glucocorticoids are widely used in KOA patients, but the safety of this technique remains open to question
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IM glucocorticoids may be an alternative
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Methods: A total of 145 patients [94 women (65%); mean age 67 years] were included in the study, of whom 138 patients (IM, 72; IA, 66) were randomly assigned to receive IM or IA 40 mg triamcinolone acetonide , and were followed up for 24 weeks
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Results: Knee pain improved in both groups at 12 weeks after injection
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At 4 weeks, the estimated mean difference in knee injury and osteoarthritis outcome scores between the two groups was −3.
4 (95% Cl −10.
1 to 3.
3), and noninferiority could not be declared
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IM was noninferior to IA injection at 8 weeks (mean difference 0.
7; 95%CI −6.
5 to 7.
8) and 24 weeks (mean difference 1.
6; 95%Cl −5.
7 to 9.
0)
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All secondary outcomes were not significantly different, similar to the results of sensitivity analyses in the intention-to-treat population
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The most common adverse reactions were hot flashes [IM (10%) vs IA (21%)] and headache [IM (14%) vs IA (18%)], but neither was serious
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 Conclusions and relevance: IM glucocorticoids were less effective than IA in reducing pain at 4 weeks
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However, at 8 weeks and 24 weeks, non-inferiority of IM was observed
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Starting from the current situation in my country, talk about the treatment of KOA patients.
Q: KOA is a common chronic degenerative joint disease.
At present, the prevalence rate of KOA in my country is 18%, and the incidence rate among people over 65 years old in my country is even higher.
80%, what is the current status of diagnosis and treatment? Professor Xie Xi: The clinical manifestations of KOA are mainly knee joint pain, movement disorder and muscle dysfunction.
It is very common in osteoarthritis.
Because it is the weight-bearing joint of the human body, it will seriously affect the quality of life of patients.
Bring a heavy psychological, social and economic burden
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The 2018 epidemiological survey shows that the total prevalence of KOA in adults in China is about 18%, and with the aging of the population, the incidence of KOA may further increase
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At present, the treatment goals of KOA are mainly to relieve pain, prevent joint deformation, improve joint function, and improve quality of life
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For KOA, there is no radical treatment, and more comprehensive treatment, including basic treatment, drug treatment, surgical treatment,
etc.

In 2019, experts in the field of rheumatism and immunity launched the "Guidelines for the Diagnosis and Treatment of Osteoarthritis in China", which are in line with China's specific conditions, integrating multidisciplinary expert advice from rheumatology, orthopedics, rehabilitation, imaging and evidence-based medicine.
The core content of KOA treatment includes weight control, especially for some obese people, which can reduce the pressure on the knee joint
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Correct self-management, including reducing long-term standing, kneeling or squatting, climbing stairs and other activities, can reduce the pressure on the knee joint and the wear and tear of the knee joint cartilage, and properly perform reasonable exercises such as knee flexion and extension activities under non-weight-bearing conditions, Avoid high-intensity bouncing sports such as basketball
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For some patients with severe KOA with limited mobility, supporters, walkers, etc.
can also be used to help the knee joint to move and recover
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KOA tends to occur in the elderly, so complications such as diabetes and cardiovascular and cerebrovascular diseases should be actively controlled
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In terms of pain improvement, topical non-steroidal anti-inflammatory analgesics (NSAIDs) are recommended to relieve mild local pain, and the lowest effective dose of oral NSAIDs should be used to control moderate to severe pain, considering the obvious side effects of opioids (especially addiction).
, is not recommended for KOA pain relief and should only be considered with caution in rare cases
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For drugs such as glucosamine or chondroitin sulfate, it is recommended to stop the drug after 3 to 6 months of use, if no symptoms improve
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For KOA patients with persistent or moderate to severe pain, IA corticosteroids are recommended
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Under the guidance of the motherland's medical theory, through syndrome differentiation and treatment, massage, massage, acupuncture, etc.
combined with external or internal use of traditional Chinese medicine can also be used as an effective choice for the treatment of KOA
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The advantages and disadvantages of IA coexist Q medical community: Currently, multiple guidelines recommend the use of IA glucocorticoids in KOA patients who are ineffective for oral or topical analgesics, and this study compared IM and IA in the treatment of KOA.
What is the significance of this study? ? Professor Xie Xi: From a clinical point of view, IA glucocorticoids can indeed quickly relieve joint inflammation and reduce local swelling, showing excellent short-term efficacy, and can also avoid systemic adverse reactions caused by the use of the hormone system, but There are also the following disadvantages: due to the short half-life of IA glucocorticoid drugs (about 1-4 h), repeated injections are required, which will inevitably increase the risk of infection, tissue damage, tendon rupture, etc.
; if there is IA glucocorticoid before knee replacement surgery History of corticosteroids and increased risk of postoperative infection
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Therefore, a number of osteoarthritis treatment guidelines at home and abroad suggest that IA glucocorticoids should not exceed 3 to 4 times a year
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IA glucocorticoids can inhibit chondrocyte proliferation, affect cartilage matrix metabolism, and promote cartilage degradation, resulting in accelerated cartilage destruction
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Because IA has higher technical requirements than IM and is more difficult to operate, and sometimes requires the use of ultrasound and other technologies to improve the accuracy of injection to reduce the risk of tissue damage, it is difficult to carry out smoothly in some primary medical institutions
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As another method of glucocorticoid administration for KOA patients, IM is simpler than IA, and it also reduces the direct impact of glucocorticoids on cartilage
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Due to the lack of a direct comparison of the analgesic effects of IM glucocorticoids and IA glucocorticoids on KOA, this study fills this gap and provides clinical decision guidance for primary medical institutions that do not have IA glucocorticoids
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 For patients, pain relief is the number one priority Q the medical community: IM has fewer adverse effects than IA as seen in the study, with more patients preferring IM to IA at baseline (47% vs 19%)
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From the perspective of clinical practice, how do you view this phenomenon? Prof.
Xie Xi: IM technology is relatively simple, and the experience of patients is better.
In theory, it is easier for patients to accept it
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The IA operation process is a little complicated, and the patient can witness the process of the doctor performing the IA during the actual clinical operation, which makes the patient more prone to nervousness during the injection process
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IA is more difficult to perform in some patients with severely limited knee motion
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But in our clinical practice, KOA patients may be more prone to IA
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The most disturbing symptom of KOA patients is knee pain and the resulting mobility impairment
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Patients' urgency for pain relief and their desire for efficacy far outweigh their fear and anxiety about IA procedures
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For patients, the intuition is that the local injection of the drug will be stronger and faster, and from a psychological perspective, the placebo effect of IA may be stronger than that of IM
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At the same time, many elderly patients with KOA have metabolic diseases such as hypertension and diabetes at the same time, which makes doctors more concerned about IM glucocorticoids and more inclined to choose IA
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IA has a quick onset of action, and IM has a longer-lasting effect.
Q medical community: From the conclusion of the article, it can be seen that the effect of IM glucocorticoid in reducing pain at 4 weeks is worse than that of IA
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But at 8 weeks and 24 weeks, the non-inferiority of IM can be observed, what do you think is the clinical significance of this? Professor Xie Xi: This research still has certain guiding significance for clinical practice
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From the 24-week follow-up results of the study, the IM group was inferior to IA in relieving KOA pain at the 4th week, but at the 8th and 24th weeks, the IM group was not inferior to the IA group; during the 24th week follow-up period , 9 patients (14%) in the IA group required repeat IA injections, but only 4 patients (6%) in the IM group
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Therefore, from the conclusion of the article, the onset of IA may be faster, but the effect of IM is more durable
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 However, in actual clinical diagnosis and treatment, this conclusion can only be used as a reference, and individualized treatment must be carried out according to the actual situation of the patient
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For example, in some patients with significantly limited knee joint movement and little joint effusion, it is difficult to perform IA.
If the patient has few comorbidities, IM glucocorticoid therapy can be considered; For patients with high risk of cardiovascular and cerebrovascular diseases who urgently need to improve KOA symptoms, IA treatment may be more appropriate
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  References[1] Qiuke Wang, MD, MSc; Marianne F.
Mol, MD et al.
Effect of Intramuscular vs Intra-articular Glucocorticoid Injection on Pain Among Adults With Knee Osteoarthritis, The KIS Randomized Clinical Trial[J].
JAMA Network Open .
2022;5(4):e224852.
Professor Xie Xi, Deputy Director, Department of Rheumatology and Immunology, Second Xiangya Hospital, Central South University, Member of the Youth Committee of the Eleventh Committee of Rheumatology Branch of Chinese Medical Association, Hunan Medical Association Rheumatology and Immunology No.
Member of the 6th Professional Committee Member of the Rare Disease Professional Committee of the Hunan Provincial Genetics Society Member of the Infectious Group of the Rheumatology and Immunology Professional Committee of the Cross-Strait Medical and Health Exchange Association, member of the IgG4-related Diseases Group Member of the Hunan Provincial Pulmonary Vascular Disease Health Management Professional Committee Member of Hunan Provincial Health Executive Director of Rheumatology and Immunity Branch of Service Industry Association Executive Editor of China Medical Education Immune System and Disease PBL Case Bank