at before, during, and after intra-articulartherapy.
Five overarching principles
The first overarching principle recognisesthe widespread use of IA therapies and thattheir use is specific to the disease that isbeing treated and “may not be interchangeable across indications,” Dr. Usón said.
The second principle concerns improvingpatient-centered outcomes, which are “thosethat are relevant to the patient,” and includethe benefits, harms, preferences, or implications for self-management.
“Contextual factors are
important and contribute to
the effect of IAT [intra-ar-
ticular treatment],” she
said, discussing the third
principle. “These include
effective communication,
patient expectations, or set-
tings [where the procedure
takes place]. In addition, one
should take into account
that the route of delivery
has in itself a placebo
effect. We found that in
different RCTs [randomised
controlled trials], the pooled
placebo effect of IA saline is
moderate to large.”
The fourth principle looks
at ensuring that patients and clinicians
make an informed and shared decision,
which is again highlighted by the first
recommendation. The fifth, and last,
overarching principle acknowledges that
IA injections may be given by a range of
healthcare professionals.
Advice for before, during,
and after injection
Patients need to be “fully informed of the
nature of the procedure, the injectable
used, and potential effects – benefits and
risks – [and] informed consent should be
obtained and documented,” said Dr. Usón,
outlining the first recommendation. “That
seems common,” she said in the interview,
“but when we did the survey, we realise
that many patients didn’t [give consent],
and the doctors didn’t even ask for it. This
is why it’s a very general statement, and
it’s our first recommendation. The agree-
ment was 99%!”
The recommendations also look at the
optimal settings for performing injections,
One recommendation states that when
intra-articular injections are being given to
pregnant patients, the safety of injected
compound must be considered, both for
the mother and for the fetus. There is
another recommendation on the need to
perform IA injections under aseptic con-
ditions, and another stating that patients
should be offered local anaesthetics, after
explaining the pros and cons.
Special populations of patients are alsoconsidered, Dr. Usón said. For example, theguidance advises warning patients withdiabetes of the risk of transient hyperglycaemia after IA glucocorticoids and theneed to monitor their blood-glucose levelscarefully for a couple of days afterward.
As a rule, “IAT is not a contraindicationto people with clotting or bleeding disorders, or taking antithrombotic medications,” she said, unless they are at a highrisk of bleeding.
Importantly, the recommendationscover when IAT can be performed afterjoint replacement surgery (after at least 3
months), and the need to “avoid overuse of
injected joints” while also avoiding com-
plete immobilisation for at least 24 hours
afterward. The recommendations very
generally cover reinjections, but not how
long intervals between injections should
be. When asked about interval duration
after her presentation, Dr. Usón said that
the usual advice is to give IA injections no
more than 2-3 times a year, but it depends
on the injectable.
“It wasn’t our intention to review the
efficacy and the safety of the different
injectables, nor to review the
use of IAT in different types
of joint diseases,” she said.
“We do lack a lot of informa-
tion, a lot of evidence in this,
and I really would hope that
new rheumatologists start
looking into and start inves-
tigating in this topic,” she
added.
Recommendations will
increase awareness of
good clinical practice
“IA injections are commonly
administered in the rheuma-
tology setting. This is because
[IA injection] is often a useful
treatment for acute flare of
arthritis, particularly when it
is limited to a few joints,” observed Dr. Ai
Lyn Tan, associate professor and honorary
consultant rheumatologist at the Leeds
(United Kingdom) Institute of Rheumatic
and Musculoskeletal Medicine.
IA injection “also relieves symptomsrelatively quickly for patients; however, theresponse can be variable, and there areside effects associated with IA injections,”Dr. Tan added in an interview.
There is a lack of universally accepted recommendations, Dr. Tan observed,noting that while there might be somelocal guidelines on how to safely perform IA injections, these were often notstandardised, and were subject to beingcontinually updated to try to improve theexperience for patients.
“It is therefore timely to learn about
the new EULAR recommendations for IA
injections. The advantage of this will be to
increase awareness of good clinical prac-
tice for performing IA injections.”
Dr. Tan had no relevant conflicts of
interest.
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