One of the most common pain relief treatments for arthritis, corticosteroid injections, may actually be associated with faster progression of the disease, according to new research.
Osteoarthritis, the most prevalent type of arthritis, occurs when the cartilage that cushions a joint breaks down over time, causing pain and stiffness. More than 32 million U.S. adults suffer from the condition, which most often affects the hands, the hips and the knees. There is no cure, but the discomfort is sometimes treated with corticosteroid shots. Hyaluronic acid injections are also used, although they’re less likely to be covered by insurance.
Two small unpublished studies, to be presented Tuesday at the Radiological Society of North America’s annual meeting, found that on average, knee arthritis advanced more quickly among patients who got corticosteroid injections than those who didn’t. By contrast, hyaluronic acid injections were associated with slower progression of the disease relative to a control group.
“Our papers show that there should be much more awareness that corticosteroids could have possible progression of OA,” or osteoarthritis, said Azad Darbandi, a medical student at the Chicago Medical School who co-authored one of the studies.
Both studies assessed patients from the Osteoarthritis Initiative, a yearslong observational research project involving nearly 5,000 people with knee osteoarthritis. Darbandi’s research analyzed X-rays from 50 patients who got corticosteroid shots, 50 who got hyaluronic acid and another 50 in a control group. The scans, collected annually for four years, revealed worse arthritis progression among participants injected with corticosteroids compared to the other two groups.
The second study, from the University of California, San Francisco, examined MRI scans from 210 participants, 44 of whom received corticosteroid shots and 26 of whom got hyaluronic acid.
The researchers looked at scans that were taken at the time of the injections, as well as two years before and after, and found more severe cartilage deterioration by the two-year follow-up mark among the steroid-taking group.
“Knowing that helps patients make a more informed choice about if they want an injection and, if they do, which injection they might prefer,” said Dr. Upasana Bharadwaj, a postdoctoral researcher in UCSF’s radiology and biomedical imaging department who co-authored the study.
But prior research on this subject is mixed. A 2019 report suggested that corticosteroid shots in the hips and the knees could accelerate the condition and even hasten the need for joint replacement operations. But an analysis last year found a similar progression of arthritis among those who got steroids and those who got hyaluronic acid.
Dr. Jonathan Samuels, a rheumatologist at NYU Langone Health, said it’s tough to determine causation in studies like the two new ones, because many factors can influence the progression of arthritis and no two patients are the same.
“We don’t have the biology to prove that the injection itself is causing accelerated damage. It’s hard to connect the dots from injection to damage from this preliminary data,” he said. “But it’s an important question, because it’s such a common practice to be injected with steroids.”
Dr. Jason Kim, vice president of osteoarthritis research programs at the Arthritis Foundation, said he’d want to see studies with a “much higher sample size over a longer period of time” before considering possible causal links.
Bharadwaj and Darbandi agreed that more research is needed, as are peer reviews for their studies.
Bharadwaj noted that her team did try to control for the possibility that people who got steroid shots were simply more likely to engage in activities that furthered the progression of their arthritis afterward. To do so, they selected participants who had maintained similar activity levels throughout the study period.
Darbandi offered a few caveats to keep in mind alongside the findings. One, he said, is that the results don’t necessarily indicate the severity of symptoms patients experienced. Just because imaging shows more arthritis progression doesn’t mean a patient feels more pain.
And second, he said, the results shouldn’t lead people to avoid corticosteroid shots in all situations.
“Even though they might progress osteoarthritis, it doesn’t mean that there’s no beneficial aspect of it or that they should not be used,” Darbandi said, “because they are effective short-term for putting a Band-Aid on the pain.”
Kim said his foundation does not recommend corticosteroids or hyaluronic acid injections for people with arthritis. Overall, he said, better treatment options are needed so that researchers don’t have to “compare one imperfect agent to another.”