Background/Purpose: The optimal dose of corticosteroid to be used in intraarticular injection is not well established. The objective of this study is to compare the effectiveness and tolerance in the medium-term between small and large doses of triamcinolone hexacetonide (TH) used in intraarticular injection (IAI) of medium size joints of patients with rheumatoid arthritis (RA).

Methods: A controlled, randomized, prospective, double-blind study was carried out  in patients with RA. It was evaluated 60 wrists joints (representing medium size joints) from the outpatient clinic at the Rheumatology Division UNIFESP, Brazil. Inclusion criteria were: patients with established RA, age between 18 and 65 years, disease modifying anti-rheumatic drugs (DMARDs) stable for at least 3 months, synovitis in wrist with pain visual analogic scale (VAS) between 4 and 8cm. Patients with overlap syndromes, polyarticular synovitis, diabetes mellitus or uncontrolled hypertension and those with suspected local or systemic infection were excluded. Patients were randomized (Clapboard randomization) in two groups of 30 patients each: group 1 (high dose) was injected with 40mg (2ml) of TH and group 2 (low dose) was injected 20mg (1ml). Only one joint was injected per patient (IAI blindly). Evaluation was conducted by a blinded observer at five times: baseline (T0), one week (T1), four (T4), eight (T8) and twelve (T12) weeks and the following assessment instruments were used: visual analogue scale for pain and swollen (swelling) (VAS 0-10cm); wrist goniometry; chronic disease activity index (CDAI). Side effects and related events were reported in a medical questionnaire. The level of statistical significance was 5%.

Results:  A total of 60 patients were injected (50 women, 37 white). Mean age was 50.0 (± 12.5) years old in the high dose group and 51.7 (± 11.6) in the low dose group (p=0.586). No statistically significant difference between groups was observed for VAS for pain, VAS for swelling, CDAI, HAQ and goniometry. But all study variables improved over time in both groups and particularly T0 improved statistically significant from all other times for VAS for pain and swelling,CDAI  and HAQ (all p<0.008). Wrist goniometry was statistically different in some periods and only in the high dose group was the improvement maintained until T12 (p<0.004). There was a significant increase of  the use of nonsteroidal anti-inflamamatory (NA) and analgesics necessary to relieve pain soon after IAI, but this use decreased after T1 equally between groups (p<0.692). Very few adverse effects and related events were reported in both groups (p=0.195).

Conclusion: There is no difference  in effectiveness of the intraarticular injection  between high and low doses of TH  used  in medium size joints of patients with RA.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/effectiveness-and-tolerance-infiltration-intraarticular-corticosteroid-according-to-dose/