Background The optimal dose of corticosteroid to be used in intraarticular injection is not well established.
Objectives The objective of this study is to compare the effectiveness and tolerance in the medium-term between small and large dose of triamcinolone hexacetonide (TH) used in intraarticular injection (IAI) of medium size joint of patients with rheumatoid arthritis (RA).
Methods A controlled, randomized, prospective, double-blind study was realized in patients with RA. It was evaluated 52 wrists joints (representing medium size joints) from the outpatient clinics at the Rheumatology Division UNIFESP, Brazil. Inclusion criteria were: patients with established RA, age between 18 and 65 years, disease modifying anti-rheumatic drugs (DMARDs) stable for at least 3 months, synovitis in wrist with pain visual analogic scale (VAS) between 4 and 8cm. Patients with overlap syndromes, polyarticular synovitis, diabetes mellitus or uncontrolled hypertension and those with suspected local or systemic infection were excluded. Patients were randomized (Clapboard randomization) in two groups of 26 patients each: group 1 (high dose) was injected with 40mg (2ml) of TH and group 2 (small dose) was injected 20mg (1ml). Only one joint was injected by patient (IAI blindly). Evaluation was conducted by a blinded observer at five times: baseline (T0), one week (T1), four (T4), eight (T8) and twelve (T12) weeks and the following assessment instruments were used: visual analogue scale for pain and swollen (VAS 0-10cm); wrist goniometry; chronic disease activity index (CDAI). Side effects and related events were reported in a medical questionnaire.The level of statistical significance was 5%.
Results A total of 52 patients were injected (43 women, 31 whites). Mean age was 49,15 (± 12,86) yearsin the high dose group and 52,34 (± 11,49) in the small dose group (p=0,431). No statistically significant difference between groups was observed for VAS for pain, VAS for swollen, CDAI and goniometry. But all study variable improve over time in both groups and particularly T0 improve statistically significant from all other times for VAS for pain and swollen and CDAI (all p<0.001). Wrist goniometry was statistically different in some times and only in the high dose group the improvement was maintained in T12 (p<0.03). Very few side effects and related events were reported in both groups (p<0.05).
Conclusions High dose of corticosteroid seems to be better at maintaining the improvement of the wrist goniometry. Intraarticular injection has good response to treat pain and swollen in RA patients and improve the CDAI regardless of the dose.
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines: Guidelines for the management of rheumatoid arthritis. Arthitis Rheum 2002;46:328-46,
Thiele K et al. Current use of glucocorticoids in patients with rheumatoid arthritis in Germany. Arthritis Rheum 2005;53:740-747,
Habib GS et al. Local effects of intra-articular corticosteroids. Clin Rheumatol 2010;29:347–356,
Konai MS et al. Monoarticular corticosteroid injection versus systemic administration in the treatment of rheumatoid arthritis patients: a randomized double-blind controlled study. Clin Exp Rheumatol 2009;27(2):214-21.
Disclosure of Interest None Declared