Updated recommendations to guide health professionals for using intra-articular therapies

"We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints." the expert team opined. The recommendations have been put forth in Annals of the Rheumatic Diseases.

Researchers aimed to establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.

Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.

The overarching principles with their agreement and the recommendations together with their agreement, level of evidence and grade of recommendation are summarized below.

1. The patient must be fully informed of the nature of the procedure, the injectable, and potential benefits and risks; informed consent should be obtained and documented according to local habits
2. An optimal setting for IAT includes:

· Professional, clean, quiet, private, well-lightened room.

· Patient in an appropriate position, ideally on a couch/examination table, easy to lie flat.

· Equipment for aseptic procedures.

· Aid from another HP.

· Resuscitation equipment close-by.

3. Accuracy depends on the joint, route of entry, and health professional expertise; if available, imaging guidance, for example, ultrasound, may be used to improve accuracy.
4. During pregnancy when injecting a joint one has to take into account whether the compound is safe for mother and baby.
5. Aseptic technique should always be undertaken when performing IAT.
6. Patients should be offered local anaesthetic explaining pros and cons.
7. Diabetic patients, especially those with suboptimal control, should be informed about the risk of transient increased glycaemia following IA GC and advised about the need to monitor glucose levels particularly from first to third day.
8. IAT is not a contraindication in people with clotting/bleeding disorders or taking antithrombotic medications, unless bleeding risk is high.
9. IAT may be performed at least 3 months prior to joint replacement surgery, and may be performed after joint replacement following consultation with the surgical team.
10. The shared decision to reinject a joint should take into consideration benefits from previous injections and other individualised factors (eg, treatment options, compound used, systemic treatment, comorbidities…).
11. Avoid overuse of injected joints for 24 hours following IAT; however, immobilisation is discouraged.

"These recommendations assume that 'best practice' is the rationale for IAT and for the selection of the compound. It was out of our scope to study and to compare the efficacy and safety of the specific IATs as well as to address the indications for the different arthropathies. When looking at contextual factors that may influence outcome, such as decrease in joint pain, we found that the procedure itself has an important placebo effect. This should be considered not only in daily practice but also when interpreting the results of RCTs comparing IAT with systemic therapy or in observational studies on IAT." said the experts.

For full article follow the link: doi: 10.1136/annrheumdis-2021-220266

Primary source: Annals of the Rheumatic Diseases