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Three Part Question

In [patients with acute rheumatoid monoarthritis] are [intra-articular steroid injections] effective in [reducing pain and swelling and improving mobility]?

Clinical Scenario

A 42 year old woman known to suffer from rheumatoid arthritis presents to the accident and emergency department with an acutely inflammed swollen knee. The patient is given an intra-articular steroid injection. You know this is a standard treatment but wonder how effective it actually is.

Search Strategy

Medline 1966-11/03 using the OVID interface.
(exp arthritis, rheumatoid/ OR monoarthritis.mp. OR exp arthritis OR exp rheumatic diseases/ OR monoarthropathy.mp.) AND (exp steroids/ or steroid$.mp. OR exp methylprednisolone/ OR methylprednisolone.mp OR exp hydrocortisone/ OR hydrocortisone.mp.) OR exp prednisolone/ OR prednisolone.mp.) AND (exp injections, intra-articular/) limited to human and English and abstracts.

Search Outcome

Altogether 215 papers found of which 214 were irrelevant or of insufficient quality. The remaining paper is shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Van Vliet-Daskalopoulou E et al, 1987, Netherlands	137 patients with classical or definite RA involving at least 1 knee joint requiring local treatment. Single intra-articular injection of rimexolone. 34 given placebo, 32 given 10mg, 33 given 20mg, 31 given 40mg. 7 patients did not fulfil protocol requirement.	Placebo-controlled double blind multicentre clinical trial	Assessment of pain, tenderness, morning stiffness, swelling, range of movement and walking ability at days 7, 28, 56, and 84 post-injection	Statistically superior clinical improvement for most variables with rimexolone at 20mg and 40mg than placebo. With the 10mg dose of rimexolone only reduction of tenderness was significantly superior. Duration of improvement longest with 40mg rimexolone. One single intra-articular injection of this dose significantly reduces pain, tenderness and stiffness and improved range of movement and walking ability for 8-12 weeks	There was a significant drop out rate (66% of 10mg group, 72% of 20mg & 71% of 40mg groups remained for rimexolone groups at the end of the study. Only 44% of placebo treated patients were still under study with the rest not accounted for 130 patients distributed over 4 groups with no sample size calculation No indication of effort made to standardise clinical variables. Since this is a multicentre trial questionable reliability and validity

Comment(s)

Acute rheumatoid monoarthritides are commonly treated with intra-articular corticosteroid injections. Although this paper indicates a favourable outcome using intra-articular rimexolone injections particularly at 40mg, the small number employed in each group may have introduced bias and the high drop out rate in the placebo group in the later stages of the study prevent efficacious comparisons to be made.

Editor Comment

Search updated in November 2003 by web editor. Original search checked by Rupert Jackson who tragically died in 2002. Obituary BMJ 2003;326:450 ( 22 February ) at http://bmj.bmjjournals.com/cgi/content/full/326/7386/450/a/DC1

Clinical Bottom Line

The available evidence suggests that a single intra-articular injection of 40mg rimexolone significantly reduces pain, tenderness and stiffness and increases mobility in patients with acute rheumatic arthritis.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Van Vliet-Daskalopoulou E, Jentjens T, Scheffer RT. Intra-articular rimexolone in the rheumatoid knee: a placebo-controlled, double blind, multicentre trial of three doses. Br J Rheumatol 1987;26:450-453.