Journal of the Chinese Medical Association
Volume 71, Issue 8 , Pages 411-415, August 2008

Effect of Intra-articular Injection of Hyaluronic Acid in Rheumatoid Arthritis Patients with Knee Osteoarthritis

  • Chen-Liang Chou

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C.
    • Department of Physical Medicine and Rehabilitation, National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C.
    • Corresponding Author InformationCorrespondence to: Dr Chen-Liang Chou, Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, R.O.C.
    • ,
  • Han-Wen Li

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C.
    • ,
  • Si-Huei Lee

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C.
    • ,
  • Ko-Lun Tsai

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C.
    • ,
  • Hsiao-Yi Ling

      Affiliations

    • Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C.
    • Department of Internal Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C.

Received 20 February 2008; accepted 15 July 2008.

Article Outline

Background

Intra-articular injection of hyaluronic acid (HA) is a well-documented treatment for knee osteoarthritis (OA). One of the multifactorial mechanisms is that exogenous HA can stimulate endogenous HA production. HA can regulate the growth and function of chondrocytes by binding to CD44 receptors on the chondrocytes. Synovitis is often found in patients with rheumatoid arthritis (RA) and is supposed to result from CD44 activity. The aim of this study was to inves-tigate the effect of intra-articular injection of HA in patients with RA combined with knee OA.

Methods

Twenty RA patients with OA knees were enrolled; 11 patients were placed into a stage II group and 9 into a stage III group, in accordance with the Kellgren-Lawrence classification of knee OA. All patients received intra-articular injection of HA (ARTZ) once a week for 5 weeks, and were evaluated with the WOMAC index (including the pain, stiffness and physical function subscales) at baseline, week 5 and week 9. The Friedman test and Wilcoxon signed rank test with Bonferroni correction method were used for statistical analysis.

Results

The effect of intra-articular injection of HA was significant at week 5 (p <0.0167) and persisted to week 9 (p <0.0167). This therapy was equally efficacious with stage II and stage III patients, with no difference between the 2 groups.

Conclusion

Intra-articular injection of HA was beneficial in patients with RA combined with knee OA.

Key Words:  hyaluronic acid , intra-articular injection , knee osteoarthritis , rheumatoid arthritis

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References 

  1. Huang MH , Yang RC , Lee CL , Chen TW , Wang MC . Preliminary results of integrated therapy for patients with knee osteoarthritis . Arthritis Rheum . 2005;53:812–820
  2. Lohmander LS, Dalen N, Englund G, Hamalinen M, Jensen EM, Karlsson K, et al  Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomized, double blind, placebo controlled multicentre trial . Ann Rheum Dis . 1996;55:424–431
  3. Moreland LW . Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action . Arthritis Res Ther . 2003;5:54–67
  4. Carr AJ . Beyond disability: measuring the social and personal consequences of osteoarthritis . Osteoarthritis Cartilage . 1999;7:230–238
  5. Scott JE . Proteoglycan: collagen interactions and subfibrillar structure in collagen fibrils: implications in the development and ageing of connective tissues . J Anat . 1990;169:23–35
  6. Lark MW , Bayne EK , Lohmander LS . Aggrecan degradation in osteoarthritis and rheumatoid arthritis . Acta Orthop Scand Suppl . 1995;266:92–97
  7. Poole CA , Gilbert RT , Ayad S , Plaas AH . Immunolocalisation of type VI collagen, decorin, and fibromodulin in articular cartilage and isolated chondrons . Trans Orthop Res Soc . 1993;18:644
  8. Balazs E . The physical properties of synovial fluid and the special role of hyaluronic acid . In:  Helfet AJ editors. Disorders of the Knee . Philadelphia: JB Lippincott; 1982;p. 61–74
  9. Wu JJ , Sih LY , Hsu HC , Chen TH . The double-blind test of sodium hyaluronate (ARTZ) on osteoarthritis knee . J Chin Med Assoc . 1997;59:99–106
  10. Aviad AD , Houpt JB . The molecular weight of therapeutic hyaluronan (sodium hyaluronate): how significant is it? . J Rheumatol . 1994;21:297–301
  11. Abatangelo G , O'Regan M . Hyaluronan: biological role and function in articular joints . Eur J Rheumatol Inflamm . 1995;15:9–16
  12. George E . Intra-articular hyaluronan treatment for osteoarthritis . Ann Rheum Dis . 1998;57:637–640
  13. Brandt KD , Smith GN , Simon LS . Intraarticular injection of hyaluronan as treatment for knee osteoarthritis: what is the evidence? . Arthritis Rheum . 2000;43:1192–1203
  14. Adams ME , Lussier AJ , Peyron JG . A risk-benefit assessment of injections of hyaluronan and its derivatives in the treatment of osteoarthritis of the knee . Drug Saf . 2000;23:115–130
  15. Dahl LB , Dahl IMS , Engstrom-Laurent A , Granath K . Concentration and molecular weight of sodium hyaluronate in synovial fluid from patients with rheumatoid arthritis and other arthropathies . Ann Rheum Dis . 1985;44:817–822
  16. Majeed M , McQueen F , Yeoman S , McLean L . Relationship between serum hyaluronic acid level and disease activity in early rheumatoid arthritis . Ann Rheum Dis . 2004;63:1166–1168
  17. Levesque H , Delpech B , Le Loet X , Deshayes P . Serum hyaluronate in rheumatoid arthritis: study by affino-immunoenzymatic assay . Br J Rheumatol . 1988;27:445–449
  18. Pitsillides AA , Worrall JG , Wilkinson LS , Bayliss MT , Edwards JCW . Hyaluronan concentration in non-inflamed and rheumatoid synovium . Br J Rheumatol . 1994;33:5–10
  19. Naor D , Nedvetzki S . CD44 in rheumatoid arthritis . Arthritis Res Ther . 2003;5:105–115
  20. Fujii K , Tanaka Y , Hubscher S , Saito K , Ota T , Eto S . Crosslinking of CD44 on rheumatoid synovial cells up-regulates VCAM-1 . J Immunol . 1999;162:2391–2398
  21. Tanaka Y , Adams DH , Hubscher S , Hirano H , Siebenlist U , Shaw S . T-cell adhesion induced by proteoglycan-immobilized cytokine MIP-1β . Nature . 1993;361:79–82
  22. Brennan FR, Mikecz K, Glant TT, Jobanputra P, Pinder S, Bavington C, et al  CD44 expression by leucocytes in rheumatoid arthritis and modulation by specific antibody: implications for lymphocyte adhesion to endothelial cells and synoviocytes in vitro . Scand J Immunol . 1997;45:213–220
  23. Linn-Rasker SP , van der Helm-van Mil AHM , Breedveld FC , Huizinga TWJ . Arthritis of the large joints—in particular, the knee—at first presentation is predictive for a high level of radiological destruction of the small joints in rheumatoid arthritis . Ann Rheum Dis . 2007;66:646–650
  24. Carmassi F , de Negri F , Morale M , Song KY , Chung SI . Fibrin degradation in the synovial fluid of rheumatoid arthritis patients: a model for extravascular fibrinolysis . Semin Thromb Hemost . 1996;22:489–496
  25. Chang X , Yamada R , Yamamoto K . Inhibition of antithrombin by hyaluronic acid may be involved in the pathogenesis of rheumatoid arthritis . Arthritis Res Ther . 2005;7:R268–R273
  26. Lussier A , Cividino AA , McFarlane CA , Olszynski WP , Potashner WJ , De Medicis R . Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada . J Rheumatol . 1996;23:1579–1585
  27. Raynauld JP, Torrance G, Band P, Goldsmith C, Tugwell P, Walker V, et al  A prospective, randomized, pragmatic, health outcomes trial evaluating the incorporation of hylan G-F 20 into the treatment paradigm for patients with knee osteoarthritis (Part 1 of 2): clinical results . Osteoarthritis Cartilage . 2002;10:506–517
  28. Listrat V, Ayral X, Patarnello F, Bonvarlet JP, Simonnet J, Amor B, et al. Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee . Osteoarthritis Cartilage . 1997;5:153–160
  29. Petrella RJ , DiSilvestro MD , Hildebrand C . Effects of hyaluronate sodium on pain and physical functioning in osteoarthritis of the knee: a randomized, double-blind, placebocontrolled clinical trial . Arch Intern Med . 2002;162:292–298
  30. Pozo MA , Balazs EA , Belmonte C . Reduction of sensory responses to passive movements of inflamed knee joints by hylan, a hyaluronan derivative . Exp Brain Res . 1997;116:3–9
  31. Smith MM , Ghosh P . The synthesis of hyaluronic acid by human synovial fibroblasts is influenced by the nature of the hyaluronate in the extracellular environment . Rheumatol Int . 1987;7:113–122
  32. McConnell S , Kolopack P , Davis AM . The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties . Arthritis Care Res . 2001;45:453–461
  33. Bellamy N , Buchanan WW , Goldsmith CH , Campbell J , Stitt LW . Validation study of WOMAC: a health status instrument for measuring clinically important relevant patient outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee . J Rheumatol . 1988;15:1833–1840
  34. Ghosh P , Guidolin D . Potential mechanism of action of intraarticular hyaluronan therapy in osteoarthritis: are the effects molecular weight dependent? . Semin Arthritis Rheum . 2002;32:10–37
  35. Wenz W , Breusch SJ , Graf J , Stratmann U . Ultrastructural findings after intraarticular application of hyaluronan in a canine model of arthropathy . J Orthop Res . 2000;18:604–612
  36. Asari A , Miyauchi S , Matsuzaka S , Ito T , Kominami E , Uchiyama Y . Molecular weight-dependent effects of hyaluronate on the arthritic synovium . Arch Histol Cytol . 1998;61:125–135
  37. Waddell DD , Bricker D . Total knee replacement delayed with Hylan G-F 20 use in patients with grade IV osteoarthritis . J Manag Care Pharm . 2007;13:113–121
  38. Waddell DD , Bricker D . Clinical experience with the effectiveness and tolerability of hylan G-F 20 in 1047 patients with osteoarthritis of the knee . J Knee Surg . 2006;19:19–27
  39. Tanimoto K, Ohno S, Fujimoto K, Honda K, Ijuin C, Tanaka N, et al  Proinflammatory cytokines regulate the gene expression of hyaluronic acid synthetase in cultured rabbit synovial membrane cells . Connect Tissue Res . 2001;42:187–195
  40. McKee CM, Penno MB, Cowman M, Burdick MD, Strieter RM, Bao C, et al. Hyaluronan (HA) fragments induce chemokine gene expression in alveolar macrophages . J Clin Invest . 1996;98:2403–2413
  41. Seghezzi G, Patel S, Ren CJ, Gualandris A, Pintucci G, Robbins ES, et al  Fibroblast growth factor-2 (FGF-2) induces vascular endothelial growth factor (VEGF) expression in the endothelial cells of forming capillaries: an autocrine mechanism contributing to angiogenesis . J Cell Biol . 1998;141:1659–1673
  42. Ishida O , Tanaka Y , Morimoto I , Takigawa M , Eto S . Chondrocytes are regulated by cellular adhesion through CD44 and hyaluronic acid pathway . J Bone Miner Res . 1997;12:1657–1663
  43. Ronchetti P, Guerra D, Taparelli F, Boraldi F, Bergamini G, Mori G, et al  Morphological analysis of knee synovial membrane biopsies from a randomized controlled clinical study comparing the effects of sodium hyaluronate (Hyalgan) and methylprednisolone acetate (Depomedrol) in osteoarthritis . Br J Rheumatol . 2001;40:158–169
  44. Pitsillides AA , Worrall JG , Wilkinson LS , Bayliss MT , Edwards JC . Hyaluronan concentration in non-inflamed and rheumatoid synovium . Br J Rheumatol . 1994;33:5–10
  45. Kobayashi K , Matsuzaka S , Yoshida Y , Miyauchi S , Wada Y , Moriya H . The effects of intraarticularly injected sodium hyaluronate on levels of intact aggrecan and nitric oxide in the joint fluid of patients with knee osteoarthritis . Osteoarthritis Cartilage . 2004;12:536–542
  46. Moreland LW . Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action . Arthritis Res Ther . 2003;5:54–67

PII: S1726-4901(08)70092-3

doi:10.1016/S1726-4901(08)70092-3

Journal of the Chinese Medical Association
Volume 71, Issue 8 , Pages 411-415, August 2008

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