EULAR releases first evidence-based recommendations for intra-articular therapies
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In an effort to “improve uniformity” and reduce the “wide variation” in intra-articular therapy use, EULAR recently published 11 new recommendations to guide clinicians in employing these therapies for patients with peripheral arthropathies.
According to the group, these recommendations – published in the Annals of the Rheumatic Diseases – are the first ever evidence- and expert opinion-based recommendations on the use of intra-articular therapies.
“There is a wide variation in the way [intra-articular therapies (IAT)] are used and delivered in patients with arthropathies,” Jacqueline Uson, MD, PhD, of the Rheumatology Hospital Universitario Móstoles, Universidad Rey Juan Carlos, in Madrid, and colleagues wrote. “Health professionals may have different views and habits depending on training and access to IATs, and individual patients also have their own needs and preferences. To the best of our knowledge, no international and multidisciplinary effort has been made to develop evidence-based recommendations when performing IAT.”
To establish recommendations based on evidence for the use of intra-articular therapies in adults with peripheral arthropathies, EULAR convened a multidisciplinary international task force that included 12 clinical experts, one rheumatology nurse and one patient representative. The clinical experts included a rheumatologist, an orthopedic surgeon, a nuclear medicine specialist and a radiologist. The task force developed objectives and the scope of their project, and performed a systemic literature review. Meanwhile, two surveys were used to assess the opinions of health care providers and patients throughout Europe.
A total of 200 participants across Europe responded to the 44-item patient survey, while 186 health care providers from 26 countries answered their survey, which featured 160 questions. The results of the literature reviewed were used to address 32 questions established by the task force. Members then discussed the evidence and survey results in a face-to-face meeting, drafting and later approving their recommendations through an anonymous three-round Delphi process.
According to the task force, the results of the patient survey suggest that the use of intra-articular therapies could be improved through, for example, greater access, better shared decision making, and more attention paid to reducing pain during the procedure. Ultimately, members of the task force approved five overarching principles and 11 recommendations, addressing issues related to patient information, procedure and setting, as well as accuracy, routine and special aseptic care, safety issues in special populations, the efficacy and safety of repeated joint injections, use of local anesthetics and aftercare.
The recommendations include:
- Patients must be fully informed of all aspects of the procedure, including about the drug and its potential benefits and risks;
- The best setting for the procedure should feature a “professional, clean, quiet, private, well-lighted” setting, with space where the patient can easily lie flat, equipment for aseptic and resuscitation measures, and aid from another health provider;
- Imaging guidance, such as ultrasound, if available, may be used to improve accuracy;
- For those who are pregnant, providers should consider whether the drug is safe for both the patient and the baby;
- Providers should always perform aseptic techniques when administering intra-articular therapies;
- Providers should offer patients anesthetics, alongside explanations of their potential risks and benefits;
- Patients with diabetes, and especially those with minimal disease control, should receive information about the risk for transient increased glycaemia following intra-articular glucocorticoids, as well as the need to monitor glucose levels, particularly from days 1 to 3;
- Intra-articular therapy is not a contraindication for people with clotting or bleeding disorders, or in those receiving antithrombotic medications, unless bleeding risk is high;
- The procedure may be administered at least 3 months prior to joint replacement, as well as after joint replacement following a consultation with the surgical team;
- Shared decision-making to reinject a joint should include considerations of the benefits seen from prior injections and individual factors, such as other treatment options and comorbidities; and
- Although immobilization is discouraged, providers should avoid the overuse of injected joints for 24 hours following the procedure.
“Despite IAT being an important procedure and widely used for more than 70 years, many aspects of IAT still need to be assessed to increase our quality of care,” Uson and colleagues wrote. “These may include safe and cost-effective settings and procedures; whether ultrasound diagnosis and guidance improve outcome; better RCTs, and perhaps a real-life registry of IATs, like the arthroplasty registers.”
The authors additionally included a “disclaimer” that the recommendations were drafted prior to the COVID-19 pandemic outbreak, and as such do not include specific safety measures to prevent SARS-CoV-2 viral infection, nor any measures to be used when having to deliver intra-articular therapy to patients with COVID-19.
“Health professionals and patients should follow local country regulations and recommendations relating to this matter,” they added. “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.”
Perspective
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David E. Bacha, MD, FACP, FACR
Intra-articular therapies have a longstanding history of utility in the treatment of a number of peripheral arthropathies. In general, rheumatologists learn how to perform intra-articular injections from their mentors and textbooks focused on the subject. The EULAR recommendations for intra-articular therapies reinforce practical aspects of intra-articular injections and provide additional guidance.
The need for a best practice approach to intra-articular injectables is emphasized in the recommendations. Highlights include the necessity for informed consent, performance of injections in the proper setting, appropriate positioning and aseptic technique. Offering patients local anesthetic and avoiding overuse of the injected joint for 24 hours is also addressed.
Systematic reviews as well as randomized controlled trials demonstrate that the accurate delivery of intra-articular therapies is improved by ultrasound guidance, but landmark-guided intra-articular injections provide similar clinical outcomes. Since most rheumatology fellowship programs offer ultrasound training as part of their curriculum, ultrasound-guided joint injections have become more readily available. However, landmark-based intra-articular injections continue to play a significant role in everyday clinical practice.
The recommendations address several special circumstances including patients who are diabetic, pregnant, taking antithrombotic medications, heading for joint replacement surgery or needing repeated injections in the same joint. Although data is limited, the authors provide a helpful recommendation that intra-articular glucocorticoid injections may be performed at least three months prior to joint replacement surgery. In light of increasing evidence that repetitive glucocorticoid intra-articular injections for knee osteoarthritis may accelerate cartilage damage, clear evidence-based recommendations regarding how often to inject the same joint in different disease states remains an unmet need.
Rheumatologists incorporate both opinion-based and evidence-based recommendations into practice in order to improve patient care. In an attempt to be more evidence-based rather than eminence-based, the EULAR recommendations for intra-articular therapies provide a framework and practical guidance for clinicians.
Perspective
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It is interesting to me that one of the most performed in-office procedures for joint pain has not had extensive studies done or evidence-based guidelines created to standardize the procedure. The multidisciplinary team focused on objectives, considered the wide variety of diagnoses that would benefit from this type of management and then made recommendations to provide the best patient outcomes regardless of setting, provider or medication used. However, much more research can be done to educate providers, reduce costs, increase patient satisfaction and improve patient outcomes.
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