Summary: viscosupplementation for the treatment of osteoarthritis of the knee

Dagenais, Pierre; Framarin, Alicia

ABSTRACT

INTRODUCTION:

Osteoarthritis (OA) of the knee is a degenerative disease that frequently results in the need for total knee replacement. This disease has been absorbing an ever-growing share of the human and financial resources of Québec's health-care system. Considered by some to be an alternative to surgery, viscosupplementation involves draining the affected knee then injecting it with hyaluronic acid. The clinical effectiveness of this procedure, which is intended to relieve pain and improve joint mobility, remains controversial.

METHODOLOGY:

The primary literature search covered a period up to September 30, 2005, with a literature watch until December 2006. Given the large number of secondary studies available, we decided to conduct an assessment of these studies. This assessment scrutinized six meta-analyses considered to be of satisfactory methodological quality. We also reviewed reports published by other health-technology assessment (HTA) agencies on topics such as the budget impact of this treatment on their respective health-care systems. Five economic studies were used to assess cost-effectiveness. Various insurance companies' health coverage policies were also reviewed. CONCLUSIONS AND

RECOMMENDATIONS:

After examining a series of meta-analyses and assessment reports on the different types of viscosupplements available, we concluded that viscosupplementation offers clinically modest relief from the symptoms of knee OA over a period that could last up to several weeks. It is furthermore a safe short-term treatment. Of note, these conclusions are based on secondary analyses of a multitude of small primary studies of poor methodological quality. Available data did not help distinguish differences in the effectiveness of any one product over the others. It was equally impossible to identify patient subgroups more likely to benefit from this treatment compared with other currently available therapeutic modalities. The cost-effectiveness of this treatment could not be established owing to discrepancies among the clinical data used and the methodological limitations of the economic studies examined. Funding this treatment would lead to a cost increase of some tens of millions of dollars per year and would command significant professional resources at a time when the health system is experiencing a labour shortage. Consequently, AETMIS considers that, given the modest effectiveness of this therapeutic treatment compared with its relatively high cost and the additional professional resources required to administer it, it is not currently justified to contemplate funding viscosupplementation for all patients with OA of the knee. It nonetheless raises the possibility that this product could be offered as a last-resort treatment to patients who do not achieve pain relief from conventional therapies or for whom these are contraindicated. The recommendation not to cover this treatment does not exclude the fact that the MSSS may examine the possibility of exceptionally offering it to people who have failed to achieve pain relief from recognized conventional treatments, as do some other third-party payers. AETMIS therefore recommends that granting agencies should encourage universities to pursue clinical research on viscosupplementation as part of the research areas or programs dedicated to musculoskeletal diseases and focused on either osteoarthritis or chronic pain.

INTRODUCTION:

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