Ropivacaine in Combination for Intrathecal Analgesia Impact Factor

The two articles in this month’s press of The Journal of Arthritis, one by Ekinci et al. titled ‘A New Treatment Option in Osteoarthritis: Prolotherapy Injections’ and the other by Senatorov et al. titled ‘Clinical Outcome of Hylan G-F 20 Injections in Shoulder and HipOsteoarthritis: A Retrospective Review’ raise several important points surrounding the topic of intra-articular injections Firstly that there is a paucity of high quality literature in the field that often leads to inconclusive or misrepresented conclusions on drug efficacy in established treatments.The articles also highlight the heterogeneity in injection procedure, site, concentration, preparation and outcome measurements. 

This editorial will, therefore, provide a concise review on some of the current injection therapies and suggest possible improvements to methodological structure to inspire readers strive for high quality data. Further, through an example of a possible novel therapy, Actovegin, this editorial will hopefully challenge readers’ way of thinking to consider the reapplication of established drugs; posing the question can you teach an old drug new tricks?

Cochrane review of 27 randomised control trials examining the effect of cortical steroid injections in Osteoarthritis reported an improved response to pain and function with cortical steroid treated patients when compared to placebo in smaller trials of low methodological quality and power with selected subgroups of patients. On the other hand larger trials with more rigorous selection criteria demonstrated limited effect of cortical steroid at 6 weeks, questioning its efficacy.Interestingly the Cochrane Musculoskeletal Group 2015 would consider cortical steroid to still be experimental in treating knee OA, they highlight two key issues for injection therapy.

The need of well-constructed, blinded, sham intervention/placebo controlled with adequately randomised and powered trials in established therapies .Obviously in a clinical setting this is not always possible, yet for upcoming therapies there is a need to strive for this gold standard of research.

The effect in meta-analyses caused by the wide variety of preparations and dosage . Should preparations such as Betamethasone, Dexamethasone, Prednisolone and Triamcinolone be evaluated under the same cortical steroid review? Certainly their efficacy should be assessed and considered individually and a dose response relationship calculated if any at all. Furthermore, most clinicians would mix a cortical steroid with different types of anaesthetic agents prior to injection; therefore their pharmacodynamics and pharmacokinetic property cannot be predicted.