Hyaluronic Acid for Treatment of Osteoarthritis of the Knee

Repeated Injections and Progression to Knee Replacement

Judith Walsh, MD, MPH

Disclosures

CTAF 

In This Article

Recommendations of Others

Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC)

BCBSA TEC published a special report in 2005 titled: Intra-Articular Hyaluronan for Osteoarthritis of the Knee which was an update from its first assessment on this topic in 1998. The special report concludes that hyaluronan "…evidence shows a statistically significant effect (positive) in almost all studies, although the magnitude and clinical significance of the effect may be small." In addition, TEC found no rigorous controlled evidence showing effectiveness of repeated treatments and attributes symptom improvement after repeated treatments attributable to either placebo effects or selection bias.

National Institute for Health and Clinical Excellence (NICE)

In February 2008, NICE issued Guidance Guideline ( ID:CG59): Osteoarthritis – the care and management of osteoarthritis in adults. Though the NICE recommendation was that "Intra-articular hyaluronan injections are not recommended for the treatment of osteoarthritis," this recommendation was based on a cost sensitivity analysis that showed that the efficacy/cost effectiveness of intra-articular hyaluronan injections "… would have to be three to five times higher than the estimates from the trials before reaching the standard threshold for cost effectiveness to the NHS."

From an evidence standpoint, p. 271 of the full guideline states that viscosupplementation "…evidence seems to suggest a benefit for reducing pain up to three months after a series of three to five injections, although the effect size is generally small."

Canadian Agency for Drugs and Technologies in Health (CADTH)

In November 2006, CADTH published Issues in Emerging Health Technologies - Intra-Articular Hyaluronic Acid (Viscosupplementation) for Knee Osteoarthritis which states that there is evidence for "modest short-term reductions in pain and improvements in function, and no superiority among HA products." In addition, the document notes that despite lack of evidence, treatments are often repeated though repeat treatments are considered safe.

Centers for Medicare and Medicaid Services (CMS)

There is not a National Coverage Determination specific to the use of this technology; reimbursement coverage is left to the discretion of local Medicare carriers.

American Academy of Orthopedic Surgeons (AAOS)

AAOS's latest guideline from 2008 – Management of Osteoarthritis in the Knee –can be found at the National Guidelines Clearinghouse website at http://www.guideline.gov/syntheses/synthesis.aspx?id=16434. AAOS did not recommend for or against viscosupplementation or the use of intra-articular HA.

AAOS was invited to provide an opinion on this technology and to send a representative to participate at the meeting. AAOS provided a written opinion on this technology reflecting their current guideline as stated above but did not send a representative to participate at the meting.

California Orthopedic Association (COA)

COA was invited to provide an opinion on this technology and to send a representative to participate at the meeting. COA did not provide an opinion on this technology nor send a representative to participate at the meeting.

American College of Rheumatology (ACR)

ACR was invited to provide an opinion on this technology and to send a representative to participate at the meeting. ACR did not provide an opinion on this technology nor send a representative to participate at the meeting.

Arthritis Foundation, Northern CA

The Arthritis Foundation was invited to provide an opinion on this technology and to send a representative to participate at the meeting. The Arthritis Foundation did not provide an opinion on this technology nor send a representative to participate at the meeting.

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