Treating Osteoarthritis of the Knee - Episode 13
Peter Salgo, MD: Let’s move on to steroids, unless there was something else you wanted to say.
Paul Lachiewicz, MD: No, we can discuss it after the steroids, because I have a comment about all of these injections and surgery.
Peter Salgo, MD: I heard, from a distinguished colleague to my right, that you can spray steroids in the same zip code and they work. I always thought you had to inject them in the joint.
Richard Iorio, MD: I also heard that Blue Cross Blue Shield of North Carolina isn’t paying for cortisone injections anymore.
Paul Lachiewicz, MD: I’m not aware of that.
Andrew Spitzer, MD: I wasn’t aware of that. There is certainly controversy with regard to hyaluronic acid (HA).
Richard Iorio, MD: Well, hyaluronic acid is controversial everywhere. But I had heard that they had made a payment decision based on discretion.
Paul Lachiewicz, MD: You can go back to them. This latest article, in our journal, shows that it is effective in a certain patient population.
Peter Salgo, MD: You do inject steroids into the joints?
Paul Lachiewicz, MD: Yes, I think that’s key.
Peter Salgo, MD: So, the cautions about steroids are the same as with the hyaluronic acid injections. You’ve got to get the right spot.
Richard Iorio, MD: Well, it’s clearly more effective if it goes in the joint.
Paul Lachiewicz, MD: There are some patients who can get some type of reaction, even from an intra-articular steroid. It’s very rare, but they go home and they say, “My blood pressure went up.” Or, “My blood sugar went up.” Or, “My face was flushed.”
Peter Salgo, MD: I’ve got to tell you, I’m surprised. I thought you guys would go, “Oh, no. We don’t do these shots.” But it does really go to what you were talking about before, which is patient-centered medicine.
Paul Lachiewicz, MD: Correct.
Peter Salgo, MD: What the patient needs. My question is, if the patient wants to dance at his wedding or his daughter’s wedding, or wants to go ski this weekend or this week because it’s the kid’s week off, is that reasonable? Is it safe? Safe is where I’m going with this.
Richard Iorio, MD: So, I’ve done it for myself, or I’ve had other people do it to me. I have asked for injections in order to perform physical tasks. But, in reality, we have nothing else to offer for immediate pain relief. We really don’t.
Andrew Spitzer, MD: I think it’s really important to also understand, in this context, the onset of action of these various different products. For this kind of immediate onset, or immediate need, or semi-immediate need, steroids are really the way to go. Hyaluronic acid may take 3 weeks, 4 weeks, or as long as 3 months to reach a peak effect. That’s not the kind of thing you want to give to a person who needs to dance at the wedding. In this patient population (who comes in and asks for an acute injection because they need to do an activity), I typically give them the injection. By the time that the event occurs, they’re usually feeling pretty comfortable.
Paul Lachiewicz, MD: I want to bring up one other point for the internist in the audience. There is now growing evidence that says that if a patient is planning to have a knee arthroplasty, they probably should not have an injection of either steroid or hyaluronic acid within 3 months of surgery.
Peter Salgo, MD: Why is that? You’re taking the joint out.
Paul Lachiewicz, MD: Well, there’s an increased risk of infection. There was this initial study from Iowa, and there was a new study from Tom Sculco, at the Hospital for Special Surgery, that will be presented at our national meeting in March. The odds/risk with either HA or steroid preparation increases the risk of infection in total knee if it’s within 3 months. So, I think we should be cognizant of that information.
Andrew Spitzer, MD: I would push that to any injection. A lot of people are injecting other types of things—platelet-rich plasma in stem cells and such. So, for any injection or any violation of the joints, I completely agree. That’s a hard line in the sand. That’s 3 months from that day—and not before—in which you want to do a joint replacement.
Paul Lachiewicz, MD: Exactly.
Peter Salgo, MD: They’re going to do this big procedure.
Transcript edited for clarity.