Is Hyaluronic Acid the Right Treatment for Your Knee Osteoarthritis?

European Experts Define the Role of Hyaluronic Acid in Knee Osteoarthritis Treatment

Knee osteoarthritis (OA) is a debilitating joint condition that can cause significant pain and impairment in mobility. Among the treatment options available, intra-articular injection of hyaluronic acid (IAAH) has gained popularity due to its ability to reduce symptoms and improve joint function. In fact, some studies suggest that the benefit/risk ratio of hyaluronic acid injections may surpass that of nonsteroidal anti-inflammatory drugs (NSAIDs). However, the level of evidence supporting its effectiveness varies, and the role of hyaluronic acid in knee OA remains complex, given the multifactorial nature of the disease.

Recently, a group of 12 European experts from the EUROVISCO group came together to define the role of viscosupplementation with IAAH in knee OA management. After careful deliberation, the group published a consensus in the journal Cartilage, offering evidence-based recommendations regarding the indications, risks, and benefits of this treatment option.

Hyaluronic Acid Injections: A Viable Option for Knee OA Patients

According to the consensus from the EUROVISCO group, IAAH injections can be considered an effective treatment for symptomatic knee OA. This applies regardless of the patient's age or other comorbidities, although caution is recommended in specific cases, such as during flare-ups or in patients with significant synovial effusion. In general, IAAH injections are well-tolerated, and the treatment shows promise in alleviating symptoms and improving function in many knee OA patients.

However, the experts emphasized the need to consider individual patient characteristics and disease severity when determining whether IAAH injections are the right course of treatment. Rather than questioning the overall effectiveness of hyaluronic acid in the general population, the consensus stresses the importance of identifying the appropriate indications for its use.

Age and Comorbidities: Considerations for Hyaluronic Acid Use

One of the advantages of IAAH injections is their good tolerability across various patient populations. According to the group’s findings, hyaluronic acid injections are suitable for patients of all ages, with no significant drug interactions or contraindications. IAAH injections are particularly recommended for frail patients (level 2B evidence), as they provide a non-invasive option for symptom management.

The treatment is also considered safe for patients with common comorbid conditions such as type 1 or type 2 diabetes, gout, metabolic syndrome, and cardiovascular or renal diseases, although the evidence supporting these uses is somewhat limited. For patients with moderate to severe obesity (BMI 30-40), IAAH injections are recommended as an option for symptomatic relief (level 1B evidence). There is less evidence for their use in individuals with morbid obesity (BMI > 40), but some experts still consider them a viable option for this group, depending on the patient’s condition and preferences.

Pregnant and breastfeeding women should approach viscosupplementation with caution. The consensus advises prioritizing intra-articular anti-inflammatory injections during pregnancy and delaying hyaluronic acid treatment until after childbirth unless severe pain demands earlier intervention, with approval from an obstetrician. A similar cautious approach is advised during breastfeeding, as viscosupplementation could potentially reduce the need for other treatment options.

When to Use Hyaluronic Acid: Timing and Inflammation

The EUROVISCO group suggests that IAAH injections may be particularly beneficial in early symptomatic knee OA, even when radiographs appear normal. This early intervention could potentially offer a “window of opportunity” for improving outcomes and slowing disease progression. For patients with mild to moderate femorotibial or patellofemoral OA, viscosupplementation can be considered, including in cases of more advanced radiographic changes. For patients who are experiencing moderate pain or who prefer to avoid surgery, IAAH may be an appropriate alternative when other options have been exhausted.

Additionally, IAAH injections are beneficial for knees with mild to moderate deformities (such as varus or valgus deformities) or those with meniscal calcinosis. The treatment is also effective for patients experiencing post-traumatic knee OA, whether for symptomatic relief or secondary prevention. IAAH is also useful in cases where synovial effusion is limited to less than 10 mL.

However, the experts cautioned that IAAH injections should not be used in certain situations. For instance, patients with large synovial effusions (> 20 mL) or acute flare-ups of knee OA are not ideal candidates for viscosupplementation. In such cases, NSAIDs, ice therapy, or intra-articular corticosteroids may be more appropriate for managing pain and inflammation.

Study Reference: https://pmc.ncbi.nlm.nih.gov/articles/PMC11577334/

Conclusion

In conclusion, hyaluronic acid injections have a well-defined role in the treatment of knee OA, especially for patients who are symptomatic but do not yet require surgery. The consensus developed by the EUROVISCO group reinforces the importance of patient-specific factors in determining the appropriateness of viscosupplementation. While the treatment is widely accepted for most knee OA patients, caution is advised in cases of significant inflammation, large synovial effusions, and during pregnancy and breastfeeding.

By providing clearer guidelines for the use of hyaluronic acid in knee OA, this expert consensus helps clinicians navigate the complexities of treatment and optimize patient outcomes.