Episode 33: The Role of Hylauronic Acid and Arthrosamid Injections in the Management of Osteoarthritis

Cortisone injections are very effective at reducing joint inflammation; however, if the pain is primarily from wear and tear rather than from inflammation, they may not work.

Join Dr Karmy for a review of alternative injections for knee osteoarthritis, which help cushion and lubricate the joint. This in-depth review will cover the pros and cons of different Hyaluronic Acid injections. We will also discuss the newest treatment for knee osteoarthritis — Arthrosamid injection.

If you have any questions for Dr. Karmy, feel free to email us at karmychronicpain@gmail.com

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Transcript

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On the plus side, compared to regenerative medicine approaches, there's definitely a financial advantage. First of all, it's covered under most private drug plans. So for patients who have a private drug plan, the injection can be free of charge. And even if the patients do have to pay for the injection out of pocket, which costs around $550 in Ontario, it is still, generally speaking, cheaper than regenerative medicine alternatives Welcome back to Chronic Pain Chronicles with Dr. Karmy, where today we explore hyaluronic acid injections and its role in treating joint pain. I'm Raveena, your host and advocate for informed, balanced conversations about living with and treating chronic pain. Joining us is Dr. Karmy, a chronic pain-focused doctor with over 20 years of medical experience, who will walk us through what hyaluronic acid injections are and how it stacks up against cortisone and regenerative medicine. And we will also discuss the different products out there because there are more options than most people realize, and they're not all the same. Hello, this is Dr. Karmy for Chronic Pain Chronicles, and today I wanted to discuss a specific type of injection which generally is referred to as viscosupplementation. It's quite a mouthful, but essentially it is an injection of hyaluronic acid, and hyaluronic acid is a substance which naturally occurs in our body, and among other functions, it is there to lubricate joints. So the hope is that if you inject some hyaluronic acid into an arthritic joint, it'll help to lubricate it and perhaps provide additional cushioning. It was developed a long time ago as an alternative to cortisone injections. There was always concern about cortisone injections causing cartilage and bone damage. Although these complications are very rare with cortisone, when they do occur, they can be quite disabling. So how does it compare to cortisone? First of all, it does not work very well for inflamed joints. If anything, it can sometimes make inflammation worse. So if somebody has a red, swollen joint that they can barely put weight on, injection of hyaluronic acid is not likely to help Second of all, at least in my clinical experience, it is less effective than cortisone in terms of percent of patients responding. With cortisone, 70% of patients will respond for three months or longer, while with hyaluronic acid, in my experience, about one in three patients responds. When they do respond, the response takes anywhere from one to four weeks to see the benefit, and on average, the response can last for about six months. Of course, that some people might get three months and some people might get a year But on average, about six months. When compared to regenerative medicine treatments such as platelet-rich plasma injections or n stride injections, my impression is that hyaluronic acid is less effective, and the duration of effect seems to be shorter. Also, hyaluronic acid does not stimulate regeneration of cartilage. On the plus side, compared to regenerative medicine approaches, there's definitely a financial advantage. First of all, it's covered under most private drug plans. So for patients who have a private drug plan, the injection can be free of charge. And even if the patients do have to pay for the injection out of pocket, which costs around five hundred and fifty dollars in Ontario, it is still, generally speaking, cheaper than regenerative medicine alternatives. So let's maybe dig in into a bit more detail and discuss different types of hyaluronic acid injections. Basically, the injections are split up on the basis of, uh, physical properties. The original hyaluronic acid injections, which came out thirty, forty years ago, consisted of relatively small molecules of hyaluronic acid. The problem with that was that they're broken down faster and frequently required multiple visits for multiple injections. On average, these products would require one injection per week for three weeks. Some examples of some of these low molecular weight injections with size of the molecules below a thousand kilodaltons include Neoviscs, Hyalgan, and Sportsvisc. Sportsvisc is a bit interesting in that it's the only product that has also been approved for tendon and ligament injections in Canada And the other advantage of these low molecular weight hyaluronic acid products is that perhaps they start working a little bit faster. Then we have large molecular weight hyaluronic acid products that are not cross-linked. These include Synolis VA and Orthovisc. Most of the time, these products only require a single visit for an injection, and they're not broken down as quickly. There's another advantage to these products, and that is that they can be mixed with platelet-rich plasma and injected in a single injection. There's increasing evidence to suggest that perhaps mixing Hyaluronic acid with PRP can give you outcomes that are better than injecting either product separately. And then we come to the hyaluronic acid products with large molecules which are cross-linked. As you would imagine, because these molecules are connected together, it takes longer to break them down, so perhaps these products last longer in the joint compared to the other two types. The common examples include Durolane, Singal, and Monovisc. Again, they just require a single injection, and at least the hope is that the benefit will last longer than with smaller molecular weight or non-cross-linked hyaluronic acid products. Let me make it clear that this has not been proven to be the case, but hyaluronic acid w- in large molecules that is cross-linked does stay in the joint for a longer period of time. Among those three products, I wanted to single out Singal. Singal is unique in that it combines cortisone with hyaluronic acid, which has its pros and cons. The advantage is that you are trying to treat the joint through two different methods and therefore, chances of responding to the injection are higher, and perhaps the response is faster. The downside is, of course, the original reason for developing hyaluronic acid injections, and that is they were trying to avoid the risk of cartilage and bone damage from cortisone. And this particular product, because it contains cortisone, can lead to damage to the bone and cartilage. Finally, I wanted to mention another product which belongs in the category of viscosupplementation products because it does provide cushioning, but it is not a hyaluronic acid product. This product is Arthrosamid. It was developed in Europe and only recently became approved in Canada. There are a number of clinics across Ontario that offer this product The advantage is that like the other hyaluronic acid products, it cushions the joints, but unlike other hyaluronic acid products, it does not degrade over time. Arthrosamid has been shown to be present in the joint for over a year, and there's some suggestion that the benefit can last for three to five years. There's also some suggestion that perhaps it is more beneficial than hyaluronic acid for more advanced grades of osteoarthritis. Generally speaking, most hyaluronic acid injections, just regenerative medicine injections, tend to work better for mild to moderate osteoarthritis and are less effective for severe osteoarthritis. There is some hope that Arthrosamid will be more effective for the severe osteoarthritis compared to some of these other products. The downsides with Arthrosamid is risk of infection. Unlike other products, with Arthrosamid, patients have to take antibiotics twenty-four-hour prior to Arthrosamid injection. There's also recommendation that Arthrosamid injection be done under ultrasound guidance, and sterility for that injection is more important than sterility for some of the other injections. And finally, there's a co-- issue of cost. Most hyaluronic acid products are covered under private drug plans, but that does not apply to Arthrosamid, and Arthrosamid can be quite expensive, costing on average around three thousand to four thousand dollars per injection. Also, for the first few months after Arthrosamid injection, it is discouraged to do any other injections into the same joint or perform knee replacement surgery. Let me make it clear that like most other interventions for chronic pain, viscosupplementation injections are controversial. There are no guidelines from rheumatological societies, orthopedic societies in North America that endorse these injections. There are, however, some studies that support their use. So what is my final takeaway on viscosupplementation? Well, I think it depends on your individual situation. If a patient responds very well to cortisone injections and they get an improvement that lasts several years, they probably don't need hyaluronic acid injections. If, on the other hand, cortisone only helps for a couple of months or less, I think it is a reasonable option, especially if you have a private drug plan. If one is paying out of pocket without a drug plan, I would go to regenerative medicine alternatives such as PRP or Anstride. And for more severe grades of osteoarthritis, perhaps combining regenerative medicine approaches such as PRP with hyaluronic acid or even trying Arthrosamid. Thank you. Thank you for listening to this episode of Chronic Pain Chronicles with Dr. Karmy, where we explored hyaluronic acid injections and their role in managing joint pain from osteoarthritis. As we've discussed, hyaluronic acid offers a different profile from cortisone and regenerative medicine options like PRP, with its own advantages in cost and coverage, but also its own limits in effectiveness and duration. Understanding these differences and where each option fits for your specific situation is key to making the right choice with your physician. At Chronic Pain Chronicles with Dr. Karmy, our goal is to bring you clear evidence-based insights so you can make informed decisions about your care. I'm Raveena Aujla. Until next time. When it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only, and should not be considered medical advice or a substitute for professional medical care.