Abstract
Objective
Although intra-articular corticosteroid injections are widely applied in the treatment of knee osteoarthritis (OA), its effect is short term. Additionally, apart from oral use, tenoxicam is also applied as an intra-articular treatment option to minimize gastrointestinal side effects of NSAIDs. Clinical evidence suggests that the combined use of NSAIDs and corticosteroids is synergistic (especially macular edema after cataract surgery in ophthalmology). Therefore, the aim of this study is to determine whether the combination of intra-articular steroid and tenoxicam was more effective for a long period rather than only tenoxicam and steroid injection alone in OA treatment.
Methods
Ninety patients were randomly divided into three groups (30 patients per group): group 1, group 2, and group 3 were treated by intra-articular injection of tenoxicam, triamcinolone hexacetonide, and triamcinolone hexacetonide plus tenoxicam, respectively. Visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were enrolled at baseline and 1, 3, and 6 months post-injection.
Results
The mean age of patients was 68.07 ± 8.08, 65.83 ± 10.13, and 67.07 ± 6.01 in group 1, group 2, and group 3, respectively. In tenoxicam group, median pre- and post-treatment (at 1, 3, and 6 months) VAS/WOMAC scores were 7.30 ± 0.53/32.50 ± 3.79, 2.27 ± 0.98/10.83 ± 2.61, 6.73 ± 1.14/30.33 ± 5.93, and 7.03 ± 0.80/31.37 ± 4.38, respectively. In steroid group, median pre- and post-treatment VAS/WOMAC scores were 7.60 ± 0.49/34.33 ± 3.40, 1.37 ± 1.21/8.83 ± 2.70, 6.87 ± 1.35/30.80 ± 7.70, and 7.27 ± 0.86/32.83 ± 4.87, respectively. In steroid plus tenoxicam group, median pre- and post-treatment VAS/WOMAC scores were 7.57 ± 0.50/33.20 ± 3.66, 0.33 ± 0.47/6.67 ± 0.95, 0.93 ± 0.98/7.87 ± 1.96, and 1.97 ± 1.12/10.43 ± 3.70, respectively. VAS and WOMAC scores in 1 month after the injection significantly decreased in both groups compared to baseline (p < 0.01). Steroid plus tenoxicam group showed significantly improved VAS and WOMAC scores when compared to only steroid and tenoxicam group at follow-up 3 and 6 months (p < 0.01).
Conclusion
The combined therapy seems to produce a more effective result for a long period than monotherapy in reducing pain and improving functional recovery.
Key points
• There is an evidence of short-term effects of intra-articular corticosteroid injection in treatment of knee OA; however, there is no consensus for the long-term benefit of this treatment yet.
• Apart from oral use, tenoxicam is also applied as an intra-articular treatment option to minimize gastrointestinal side effects of NSAIDs.
• Clinical evidence suggests that the combined use of NSAIDs and corticosteroids is synergistic (especially macular edema after cataract surgery in ophthalmology).
• The combined therapy seems to produce a more effective result for a long period than alone therapy.
Similar content being viewed by others
References
Felson DT (1988) The epidemiology of hip and knee osteoarthritis. Epidemiol Rev 10:1–28. https://doi.org/10.1093/oxfordjournals.epirev.a036019
Lawrence RC, Hochberg M, Kelsey JL, McDuffie FC, Medsger TA Jr, Felts WR, Shulman LE (1989) Estimates of prevalence of selected arthritic and muskuloskeletal diseases in the United States. J Rheumatol 16:427–441. https://doi.org/10.1002/1529-0131(199805)41:5<778::AID-ART4>3.0.CO;2-V
Papathanassiou NP (1994) Intra-articular use of tenoxicam in degenerative osteoarthritis of the knee joint. J Int Med Res 22:332–337. https://doi.org/10.1177/030006059402200604
Sinusas K (2012) Osteoarthritis: diagnosis and treatment. Am Fam Physician 85:49–56 https://www.aafp.org/2012/0101/p49.html
Balch HW, Gibson JM, El- Ghobarey AF, Bain LS, Lynch MP (1977) Repeated corticosteroid injections into knee joints. Rheumatol Rehabil 16:137–140
(2000) Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update, American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 43:1905. https://doi.org/10.1002/1529-0131(200009)43:9<1905::AID-ANR1>3.0.CO;2-P
Gaffney K, Ledingham J, Perry JD (1995) Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis 54:379–381. https://doi.org/10.1136/ard.54.5.379
Evcik D, Kızılay B, Maralcan G (2003) The efficacy of intraarticular tenoxicam in the treatment of knee osteoarthritis. Pain Clinic 15:405–408. https://doi.org/10.1163/156856903770196773
Maricar N, Callaghan MJ, Felson DT, O’Neill TW (2013) Predictors of response to intra-articular steroid injections in knee osteoarthritis- a systematic review. Rheumatology 52:1022–1032. https://doi.org/10.1093/rheumatology/kes368
Malik A, Sadafale A, Gupta YK, Gupta A (2016) A comparative study of various topical nonsteroidal anti-inflammatory drugs to steroid drops for control of post cataract surgery inflammation. Oman J Ophthalmol 9:150–156. https://doi.org/10.4103/0974-620X.192268
Huskisson EC (1974) Measurement of pain. Lancet 2:1127–1131
Jahangier ZN, Moolenburgh JD, Jacobs JWG, Serdijn H, Bijlsma JWJ (2001) The effect of radiation synovectomy in patients with persistent arthritis: a prospective study. Clin Exp Rheumatol 19:417–424
Beyaz SG (2012) Comparison of efficacy of intra-articular morphine and steroid in patients with knee osteoarthritis. J Anaesthesiol Clin Pharmacol 28:496–500. https://doi.org/10.4103/0970-9185.101940
McAlindon TE, Bannuru RR, Sullivan MC, Arden NK et al (2014) OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil 22:363–388. https://doi.org/10.1016/j.joca.2014.01.003
Harvey WF, Hunter DJ (2008) The role of analgesics and intra-articular injections in disease management. Rheum Dis Clin N Am 34:777–788. https://doi.org/10.1016/j.rdc.2008.05.006
Erbas M, Simsek T, Kiraz HA, Sahin H, Toman H (2015) Comparison of the effectivity of oral and intra-articular administration of tenoxicam in patients with knee osteoarthritis. Braz J Anesthesiol 65:333–337. https://doi.org/10.1016/j.bjane.2013.12.003
Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan JL, Protheroe J, Jordan KP (2015) Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. Osteoarthr Cartil 23:507–515. https://doi.org/10.1016/j.joca.2014.11.019
Okada A, Okada Y (2009) Progress of research in osteoarthritis: metalloproteinases in osteoarthritis. Clin Calcium 19:1593–1601 CliCa091115931601
Fukuda K (2009) Progress of research in osteoarthritis: involvement of reactive oxygen species in the pathogenesis of osteoarthritis. Clin Calcium 19:1602–1606 CliCa091116021606
Kapoor M, Martel-Pelletier J, Lajeunesse D, Pelletier JP, Fahmi H (2011) Role of proinflammatory cytokines in the pathophysiology of osteoarthritis. Nat Rev Rheumatol 7:33–42. https://doi.org/10.1038/nrrheum2010.196
Yavuz U, Sokucu S, Albayrak A, Ozturk K (2012) Efficacy comparisons of the intraarticular steroidal agents in the patients with knee osteoarthritis. Rheumatol Int 32:3391–3396. https://doi.org/10.1007/s00296-011-2188-0
Cheng OT, Souzdalnitski D, Vrooman B, Cheng J (2012) Evidence-based knee injections for the management of arthritis. Pain Med 13:740–753. https://doi.org/10.1111/j.1526-4637.2012.01394.x
Garg N, Perry L, Deodhar A (2014) Intra-articular and soft tissue injections, a systematic review of relative efficacy of various corticosteroids. Clin Rheumatol 33:1695–1706. https://doi.org/10.1007/s10067-014-2572-8
Unlu Z, Ay K, Tuzun C (2006) Comparison of intra-articular tenoxicam and oral tenoxicam for pain and physical functioning in osteoarthritis of the knee. Clin Rheumatol 25:54–61. https://doi.org/10.1007/s1067-005-1136-3
Ozkan FU, Uzer G, Turkmen I, Yıldız Y, Senol S, Ozkan K et al (2015) Intra-articular hyaluronate, tenoxicam and vitamin E in a rat model of osteoarthritis: evaluation and comparison of chondroprotective efficacy. Int J Clin Exp Med 8:1018–1026
Orak MM, Ak D, Midi A, Lacin B, Purisa S, Bulut G (2015) Comparison of the effects of chronic intra-articular administration of tenoxicam, diclofenac and methylprednisolone in healthy rats. Acta Orthop Traumatol Turc 49:438–446. https://doi.org/10.3944/AOTT.2015.14.0312
Godwin M, Dawes M (2004) Intra-articular steroid injections for painful knees. Systematic review with meta-analysis. Can Fam Physician 50:241–248
Arroll B, Goodyear-Smith F (2004) Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ 328:869. https://doi.org/10.1136/bmj.38039.573970.7C
Rozental TD, Sculco TP (2000) Intra-articular corticosteroids: an updated overview. Am J Orthop (Belle Mead NJ) 29:18–23
Dieu-Donne O, Theodore O, Joelle ZT, Pierre D, Smalia O, Christian C et al (2016) An open randomized trial comparing the effects of oral NSAIDs versus steroid intra-articular infiltration in congestive osteoarthritis of the knee. Open Rheumatol J 10:8–12. https://doi.org/10.2174/1874312901610010008
Rhen T, Cidlowski JA (2005) (2005) Antiinflammatory action of glucocorticoids-new mechanisms for old drugs. N Engl J Med 20(353):1711–1723. https://doi.org/10.1056/NEJMra050541
Russo A, Costagliola C, Delcassi L, Parmeggiani F, Romano MR, dell’Omo R, Semeraro F (2013) Topical nonsteroidal anti-inflammatory drugs for macula edema. Mediat Inflamm 2013(476525):1–11. https://doi.org/10.1155/2013/476525
Schoenberger SD, Kim SJ (2013) Nonsteroidal anti-inflammatory drugs for retinal disease. Int J Inflam 2013(281981):1–8. https://doi.org/10.1155/2013/281981
Moore N, Pollack C, Butkerait P (2015) Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs. Ther Clin Risk Manag 11:1061–1075. https://doi.org/10.2147/TCRM.S79135
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
The study protocol was approved by the Ethical Committee of Kocaeli University (Trial registration: KU GOKAEK 2017/106). Written informed consent was obtained from all patients.
Disclosures
None.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Yilmaz, E. The evaluation of the effectiveness of intra-articular steroid, tenoxicam, and combined steroid–tenoxicam injections in the treatment of patients with knee osteoarthritis. Clin Rheumatol 38, 3243–3252 (2019). https://doi.org/10.1007/s10067-019-04641-y
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10067-019-04641-y