Hyaluronic Acid Injections in the Treatment of Osteoarthritis Secondary to Primary Inflammatory Rheumatic Diseases: A Systematic Review and Qualitative Synthesis

Abstract

The purpose of this study is to review the current literature on the use of hyaluronic acid (HA) specifically applied to the treatment of osteoarthritis (OA) secondary to primary inflammatory rheumatic diseases. Osteoarthritis should be carefully considered because it has potentially devastating effects on health-related quality of life. Locally injected HA seems to be an effective treatment for OA but it is not clear how to place this treatment in the context of inflammatory rheumatic disorders. To retrieve relevant articles, we conducted the search through MEDLINE, EMBASE and Cochrane Databases performing the PICO strategy. We finally selected four randomized clinical trials and six observational studies and grouped them in accordance with its main objective within three focuses: the clinical effect of HA therapy in joints without any signs of inflammation, the clinical effects of HA therapy in joints with active synovitis, and the involvement and changes of synovial fluid in the treatment of secondary OA. Our qualitative analysis clearly showed that the current literature is marked by high levels of heterogeneity and therefore difficult to interpret. Therefore, our hypothesis that viscosupplementation should be considered as a treatment for chronic moderate symptomatic OA secondary to inflammatory rheumatic diseases, and not for flares with joint swelling, cannot be definitely supported. Welldesigned studies are necessary to definitively clarify the range of application of intra-articular HA injections in the treatment of inflammatory rheumatic disorders.

Hyaluronic Acid: A Key Ingredient in the Therapy of Inflammation

“…Osteoarthritis (OA) is an inflammatory pathology of the diarthrodial joints, characterized by chronic and progressive cartilage degeneration, the formation of osteophytes, subchondral sclerosis, bone hypertrophy and changes in the synovial membrane [11,76,77]. HA is found in the joint, providing viscoelastic properties to the synovial fluid [23,24,78]. The onset of OA, associated with reduced HA synthesis and increased degradation, leads to a shift in distribution towards a lower average MW in the synovium, synovial cavity and cartilage, which consequently decreases the mechanical and viscoelastic properties of the synovial fluid in the affected joint [23,24].…”

Hyaluronic Acid in Orthopedics

“…De Lucia et al in 2020, they reviewed the systematic work comparing the effects of HA and corticosteroids (GKS) in intra-articular injection [23]. A total of 370 HA administrations were evaluated for eight different joints (shoulder, knee, ankle, foot, elbow, wrist, fingers and toes).…”

“…The assessment of treatment effectiveness was performed using various scales of function and pain disorders. In summary, each study resulted in an improvement in joint function and a reduction in pain compared to baseline [23]. Saito et al concluded that, regardless of the joint, both HA and GKS showed similar efficacy in the treatment of rheumatoid arthritis (RA) i OA [24].…”

An Investigator-Initiated, Prospective, Single-Center, Open-Label Clinical Study to Evaluate Safety and Performance of Intra-Articular Hyaluronic Acid (IA-HA) (Biovisc Ortho) in Patients with Osteoarthritis (OA) of the Knee

“…The elasticity and viscosity of synovial fluid are maintained by the HA in normal knee joints. [3][4][5][6] Intra-articular therapeutic modality is preferred over analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) for knee OA management due to significant toxicity and poor tolerability by OA patients with comorbidities. 5 Intra-articular HA is either naturally derived from avian or through bacterial fermentation.…”