A task force convened by the European Alliance of Associations for Rheumatology (EULAR) released evidence-based recommendations regarding the use of intra-articular therapies (IATs) in adult patients with peripheral arthropathies. The recommendations were published in Annals of the Rheumatic Diseases.
Intra-articular therapies involve the injection of therapeutic agents, such as glucocorticoids, local anesthetics, hyaluronic acid, autologous blood products, and radiopharmaceuticals, into joints to relieve pain and swelling. Although IATs are being widely used in health care settings, no evidence-based recommendations had been developed. To address this gap, the EULAR established a task force of experts to develop recommendations for the use of IAT in adult patients with peripheral arthropathies.
The task force included 2 conveners, a methodologist, 2 fellows, and 12 multidisciplinary clinical experts from 6 European countries. Two in-person meetings were conducted. The first meeting established objectives and priorities, following which a series of systematic literature reviews were conducted. Surveys were also developed for health care professionals to understand current clinical practices and patients to solicit their experiences with IAT. At the second meeting, the task force evaluated the systematic reviews and survey results and developed initial recommendations. A 3-round Delphi process was used to establish agreement for the recommendations, using a 65% agreement threshold for the first round and an 80% threshold for the second round. The final recommendations were given a level of evidence and grade according to the Oxford levels of evidence.
Overall, the task force established 5 overarching principles and 11 recommendations for IAT use in adults with peripheral arthropathies.
- IATs are recommended and widely used in the management of joint diseases. Guidance regarding the use of IATs are included in several condition-specific EULAR recommendations, such as knee osteoarthritis, gout, rheumatoid arthritis, and hand osteoarthritis
- IATs should be evidence-based and used to improve patient-centered outcomes.
- Contextual factors, such as effective communication, patient expectations, and the setting in which the procedure takes place, may influence the outcome of IATs. In addition, IATs may have a placebo effect that should be considered by health care professionals.
- When offering IAT, health care professionals should use a shared decision-making process that includes patient preferences.
- Health care professionals, including general practitioners, rheumatologists, orthopedic surgeons, nurses, and physical therapists, perform IAT routinely, depending on country regulations.
- Patients should be fully informed about the procedure, potential benefits and harms, side effects, and postinjection care. Informed consent should be documented according to country regulations.
- Health settings may impact the outcome of IATs. The optimal setting is professional, clean, quiet, private, and well-lighted. The patient should be in an appropriate position, preferably on a couch or exam table. Equipment for aseptic procedures must be available, along with resuscitation equipment. In addition, another health care professional should be close by in the event of a vasovagal reaction.
- The accuracy of the IAT depends on the joint, route of entry, and experience of the health care professional. If available, ultrasound may be used to improve accuracy.
- When performing IATs during pregnancy, the safety of the agent for the mother and baby should be considered. Most agents are safe for use during pregnancy, except for radiopharmaceuticals.
- An aseptic technique should always be followed when performing an IAT.
- A local anesthetic should be offered after a discussion of the risks and benefits of its use. Surveys have revealed the inconsistent use of local anesthetics by health care professionals, even though patients expressed a desire for less painful procedures.
- For patients with diabetes, especially among those whose disease is not well-controlled, there is an increased risk for transient hyperglycemia following glucocorticoid injection. Patients should be counseled about this risk and be advised to monitor glucose levels from day 1 to 3 after injection.
- IAT is a low-bleeding risk procedure and is not contraindicated for individuals with clotting/bleeding disorders or those receiving antithrombotic medications, unless the bleeding risk is high.
- IATs may be performed at least 3 months before joint replacement surgery. After joint replacement, injection into the prosthetic joint can be considered following consultation with the surgeon and screening for prosthetic infection.
- There are no clear evidence-based recommendations that evaluate the effects of repeating intra-articular injections. When deciding whether to reinject a joint, a shared decision-making process should be used to evaluate the success of previous injections and other patient-specific factors, such as treatment options, compounds, systemic treatment, and comorbidities.
- Patients should avoid overusing injected joints for 24 hours after the IAT; however, immobilization is discouraged.
The EULAR task force noted several aspects of IATs that warrant further study, such as the safety and cost-effectiveness of different settings and procedures and whether ultrasound diagnosis and guidance improve outcomes. The task force also recommended additional randomized control trials as well as the development of an IAT registry, such as those established for arthroplasty.
They concluded, “We expect these first recommendations to be included in different educational [programs], used by patient associations, and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.”
Uson J, Rodriguez-García SC, Castellanos-Moreira R, et al. EULAR recommendations for intra-articular therapies. Ann Rheum Dis. Published online May 25, 2021. doi:10.1136/annrheumdis-2021-220266.