Why we should definitely include intra-articular hyaluronic acid as a therapeutic option in the management of knee osteoarthritis: Results of an extensive critical literature review.
OBJECTIVES:There is a discrepancy between evidence in support of the widespread use of intra-articular hyaluronic acid (IAHA) to treat knee osteoarthritis (OA) in clinical practice, and the often discordant recommendations from multiple international guideline committees, which requires further investigation. METHODS:
We conducted a literature review to determine the strength of evidence in support of the efficacy and safety of IAHA, from randomized controlled trials and meta-analyses. RESULTS: Our analysis shows that IAHA provides a moderate symptomatic benefit to knee OA patients and without major safety concerns. In fact, IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. CONCLUSIONS: We advocate for the consideration of recommending IAHA injection as a treatment option in the management of knee OA, tailored by disease stage and patient phenotype. Future research efforts should focus on identification of OA patient subgroups that demonstrate a more robust response to IAHA, determination of long-term effects of repeat IAHA injections on patient-reported outcomes and total knee replacement-sparing effect, further elucidation of disease-modifying effects, and the potential for combination therapy with other pharmacologic and non-pharmacologic therapies to optimize the management of knee OA (1).

Hyaluronic acid vs corticosteroids in symptomatic knee osteoarthritis: a mini-review of the literature.
INTRODUCTION: Although intra-articular injections of hyaluronic acid (HA) are common non-operative measures used in clinical practice in the management of symptomatic osteoarthritis, there is a great controversy on their efficacy and safety compared to corticosteroids (CSs). EFFICACY: Conflicting results have been reported in clinical trials and meta-analysis due to methodological differences in study design, along with collection, analysis, and interpretation of data. Even if some studies reported small or no differences of HA compared with CSs (or inferred that HA is not more effective than saline as a placebo), in general CSs have shown to be superior in the short term (especially on pain control), while better results have been reported with HA at subsequent evaluations, but with only a moderate effect after 26 weeks. SAFETY: Mild or moderate adverse events have generally been reported after HA injections, the most common being injection site pain. HA is generally considered safe compared to CSs or saline. Furthermore, HA has shown to be safe also after a previous course of injections.CONCLUSIONS: Conflicting results have been reported on the efficacy and safety of HA. Guidelines are controversial and in most of the cases "uncertain" recommendations are provided due to inconclusive evidence in literature. However, HA does not seem to have significantly higher side effects when compared to saline or CSs injections, and provides better medium-term control of symptoms in patients with mild to moderate knee osteoarthritis (2).

References______________________________

(1) Why we should definitely include intra-articular hyaluronic acid as a therapeutic option in the management of knee osteoarthritis: Results of an extensive critical literature review.
Maheu E, Bannuru RR, Herrero-Beaumont G, Allali F, Bard H, Migliore A.
Semin Arthritis Rheum. 2019 Feb;48(4):563-572. doi: 10.1016/j.semarthrit.2018.06.002. Epub 2018 Jun 19. Review.

(2) Hyaluronic acid vs corticosteroids in symptomatic knee osteoarthritis: a mini-review of the literature.
Bisicchia S, Tudisco C.
Clin Cases Miner Bone Metab. 2017 May-Aug;14(2):182-185. doi: 10.11138/ccmbm/2017.14.1.182. Epub 2017 Oct 25.