Monday, November 16, 2015

Hyaluronic Acid Injections at the ACR 2015 Meeting in San Francisco

There have been two publications on hyaluronic acid injections at the ACR 2015 Annual Meeting in San Francisco.

Kevin Ong and colleagues analyzed retrospective data: “Hyaluronic Acid Injections in Knee Osteoarthritis Patients Are Associated with Delay to Knee Arthroplasty”. They concluded: “Our analysis of elderly knee OA patients showed a significantly longer delay to KA [knee arthroplasty] for those who were treated with HA [hyaluronic acid].” The authors presented a retrospective, observational study, which cannot take into account the placebo effect of an injection. It lacks a control group. Or do we have a control group?
Astrid in “Fringe” asked Dr. Walter Bishop: “What’s this?” And Walter answered: “A watermelon as a control group.”
I don’t see the two groups comparable; the second group isn't a control group. The time intervals are differently fixed: one with the treatment and the other one arbitrarily.
There may be other reasons as well: different coping attitudes (one trying to avoid arthropasty and the other wishing an arthroplasty), waiting for therapeutic effect or others.
All in all, I don’t think that this study has a good point to convince us of using hyaluronic acid in delaying the time to knee arthroplasty.

Gurjit S. Kaeley and colleagues also used retrospective data in their study: “Utilization of Viscosupplementation: 2011 – 2013”. The authors wanted to estimate and compare the prevalence and cost of Viscosupplemention utilization as recent “ American Academy of Orthopedic Surgeons (AAOS) guidelines have strongly recommended against use of hyaluronic acid because of lack of clinical improvement compared with placebo.” The authors concluded: “This study highlights the significant cost of VS [viscosupplementation ] in the Medicare population. […] In view of the negative recommendations by the AAOS [American Academy of Orthopedic Surgeons] against the use of Hyaluronic acid joint injections, the current trajectory of use of Hyaluronic acid may not represent optimal value care.”

Hyaluronic acid in knee osteoarthritis hasn’t proven efficacy like clinical improvement compared with placebo or delaying the time to knee arthroplasty. Therefore guidelines recommend against using it.
In Germany hyaluronic acid injections aren’t covered by the compulsory health insurance system, so patients have to pay for injection and medication.
I would not use hyaluronic acid in knee osteoarthritis.

Ong K, Anderson A, Lau E, Niazi F, Fierlinger A, Kurtz S, Altman R. Hyaluronic Acid Injections in Knee Osteoarthritis Patients Are Associated with Delay to Knee Arthroplasty [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). Accessed November 16, 2015.

Kaeley GS, Thway M, Dodani S. Utilization of Viscosupplementation: 2011 – 2013 [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). Accessed November 16, 2015.


  1. The global hyaluronic acid injections market is estimated to reach US$ 11.5 Billion by 2021, expanding at a CAGR of 8.8% from 2017 to 2021. Market by product (single-injection cycle products, three-injection cycle products, five- injection cycle products), applications (osteoarthritis, ophthalmic, dermal fillers, vesicoureteral reflux). Major players include Allergan,Inc., Anika Therapeutics, Inc., Merz Aesthetics, Inc., Sanofi (Genzeyme) and Seikagaku. - iHealthcareAnalyst, Inc.

    1. Yes, it's a big market. It only shows how easy one can deceive people if fears and hopes of patients play a role. Hyaluronic acid injections have failed to prove an advantage for the patient - there are of course advantages for the companies, you've mentioned, and the one, who does the injection.