Background Corticosteroid (CS) injections are commonly used to treat musculoskeletal pain and inflammation. The comparative efficacy of various CS preparations used for such injections has not been systematically studied.
Objectives To compare the relative efficacy of various CS and different doses used for injections in treating joint and soft tissue pain and inflammation.
Methods MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effectiveness were searched to find randomized controlled trials comparing two CS or two doses of a CS used for the treatment of arthritis and periarticular or regional pain syndromes (e.g. tendonitis, bursitis, epicondylitis, carpal tunnel syndrome, and trigger finger). A qualitative methodological assessment was done based on randomization, sample size, blinding and outcome measures.
Results Out of the 207 articles identified by the initial search, 19 met the inclusion criteria for final review. Six trials comparing methylprednisolone (MP) with triamcinolone (TC) had conflicting results for superior efficacy for various indications as follows: five trials showed superiority of triamcenolone hexacetonide (TH) over MP in knee arthritis, two trials showed a possible faster onset of action with MP and two trials showed equal overall efficacy. Four trials compared TH with triamcinolone acetonide (TA) and reported greater efficacy, faster onset or longer duration of action for TH (59% vs. 44% pain reduction; two year response rate 77% vs. 38%; relapse rate 1.4 vs. 4.2; and time to relapse 10 months vs. 8 months). TH had a faster onset of action although similar overall efficacy compared to prednisolone-t-butyl acetate; but a superior efficacy compared to MP (60% vs. 30% response at one year); betamethasone (BM) (duration of response 2.5 months vs 1.3 months); and hydrocortisone (HC); as well as an overall longest duration of response (176 vs 125 vs 79 days for TH, MP and BM, respectively) for knee injections in patients with osteoarthritis (OA), rheumatoid arthritis (RA) or juvenile idiopathic arthritis (JIA). We found one trial each showing equal efficacy of hydrocortisone acetate and hydrocortisone tertiary-butyl-acetate for knee OA; and similar efficacy but faster onset of action for TH and dexamethasone (DM) for trigger finger. Another trial showed greater efficacy and longer benefit (19 vs 13 days) of MP compared to HC for knee arthritis. Three trials on TA found 40 mg dose to be equally efficacious as 20 mg but better than 10 mg, with a faster and longer lasting effect for non-inflammatory painful shoulder. There was no additional benefit of a second injection.
Conclusions Although results are conflicting for overall efficacy, trends favor TH over other CS (TA, MP, BM, DM, and HC) for knee involvement in RA, OA or JIA. TH has longer duration and faster onset of action for subacromial bursitis and adhesive capsulitis compared to other CS preparations.
Disclosure of Interest N. Garg: None Declared, A. Deodhar Grant/research support from: This work was supported by an unrestricted educational grant of 4500 $ from American Regent to the Oregon Health & Science University Fellowship Fund.