Therapeutic Review of Methylprednisolone Acetate Intra‐Articular Injection in the Management of Osteoarthritis of the Knee – Part 2: Clinical and Procedural Considerations

Abstract

The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.

Clinical Effect of Bushen Huoxue Method Combined with Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis and Its Effect on IL-1, IL-6, VEGF, and PGE-2

“…Damaged articular cartilage can lead to the reduction of joint to resist mechanical stress, which further induces meniscus injury, ligament injury, and subchondral bone injury, resulting in further deterioration of joint function [ 28 ]. At present, the clinical treatment methods for KOA mainly include oral anti-inflammatory drugs, joint cavity injection, physiotherapy, but the long-term effect is not satisfactory, especially for patients with intermediate and advanced KOA [ 29 , 30 ]. More and more studies are focusing on the cartilage level of the knee joint in order to find a more effective treatment for KOA.…”

The Safety of Continued Oral Anticoagulation Therapy in Joint Injections and Aspirations

“…There is a growing body of evidence that the traditional practice of anticoagulation discontinuation, reversal with infusions of coagulation factor concentrates, or bridging with heparin may no longer be necessary. Instead, ensuring that anticoagulation is within the therapeutic range for warfarin, and timing procedures during trough concentration periods for direct oral anticoagulants (DOACs) may help minimize bleeding complications 5–7 …”

Peri‐procedural management and incidence of bleeding events following musculoskeletal injections or aspirations in people on oral anticoagulation and antiplatelet therapy

“…The current study reinforces the need for warnings that localised bruising is a common consequence, and although risks appear very low, providing advice on what to do if a bleeding event occurs and strong clarity regarding reversal issues are also important. Finally, technical skill in relation to iatrogenic trauma (McCrum, 2016) or procedures which may require multiple attempts or prolonged procedures may require additional considerations with anticoagulated patients (Kaye et al., 2019).…”