EULAR releases first guidance for intra-articular injections in arthropathies
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A EULAR task force has published the first evidence-based recommendations to guide clinicians administering intra-articular injections in patients with arthropathies, according to data presented at the EULAR 2020 E-Congress.
“There is a wide variation in the way intra-articular therapies are used and delivered in patients,” Jacqueline Uson Jaeger, MD, of Mosteles University Hospital, in Spain, said in her presentation. “Health professionals have different views and habits depending on geographic location, health systems, training and age. All of this may influence the efficacy and safety of intra-articular therapy.”
Jaeger suggested that the “complexity of this topic” and the “paucity of evidence” were likely reasons why no such guidelines had previously been developed.
The group used EULAR standardized operational procedures to develop 32 Population/Problem, Intervention, Comparison and Outcome (PICO) questions in seven different categories. They conducted six searches of literature on intra-articular injections administered between 1946 and 2019.
“Our main objective was to establish evidence-based recommendations to guide health professionals using intra-articular therapies, or IAT, in adult patients with arthropathies,” Jaeger said.
She added that the group acknowledged the challenge of this endeavor, given that intra-articular therapy is used in a range of conditions, from osteoarthritis to types of synovitis. To combat this challenge, two surveys were developed, one that contained 160 items for health professionals and one that contained 44 items for patients. They received 186 responses from health professionals and 200 responses from patients.
The resulting document contains five over-arching principles and 11 recommendations.
The first principle states that intra-articular injections are widely used in myriad joint diseases. The second states the aim should be tailored to the specific target. The next recommends the dose needs to be defined for each indication and joint. Another is that the group aims to improve patience-centered outcomes, including benefits, harms and implications for self-management.
Also, contextual factors are important and contribute to the effects of injections. “In addition, one should take into account that route of delivery has in itself a placebo effect,” Jaeger said.
The last principle is that a variety of health professionals administer intra-articular therapy routinely.
Turning to the actual recommendations, the first states the patient must be fully informed of the nature of the procedure. “Consent should be obtained,” Jaeger said.
Next, the setting of the injection should be “optimal,” according to Jaeger. She described this setting as clean, well-lighted, with the appropriate equipment and the patient in the appropriate position.
Third, accuracy depends on the joint, and the route of entry depends on operator expertise. “Imaging guidance can be used if available,” Jaeger said.
The fourth recommendation ensures the safety of compounds delivered in pregnant women, while the fifth asserts that a septic technique should always be used. The sixth emphasizes that the patient should be offered local anesthesia.
For the seventh recommendation, Jaeger noted that patients with diabetes should be informed of the risk for transient hypoglycemia with intra-articular injections.
The eighth recommendation stipulates that intra-articular injection is not contraindicated in patients with blood clotting or bleeding disorders unless bleeding risk is high.
For the ninth recommendation, Jaeger noted that injections may be administered at least 3 months before and 3 months after joint replacement surgery.
“Ten, a shared decision to reinject should take into consideration benefits from previous injections and other individualized factors, like treatment options, compounds used, systemic treatments and comorbidities,” Jaeger said.
The final recommendation suggests that overuse of the joint 24 hours after injection should be avoided. “However, immobilization is discouraged,” Jaeger said.
“We really hope that these recommendations will really help uniformity and quality of care,” Jaeger concluded. “Ideally, the lay summary should be translated into different EULAR languages and recommendations should be disseminated via patient associations and, hopefully, also, through different scientific societies. We hope this project will help encourage research in this very important area.”
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Jaeger JU, et al. Recommendations for intra-articular treatment for arthropathies. Presented at: EULAR 2020 E-Congress; June 3-6, 2020 (virtual meeting).
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