Indication(s)
Management of joint pain in osteoarthritis (OA) of the knee in those who have failed to respond to non-pharmacological treatment and trials of simple analgesics. Select viscosupplements are also indicated for management of OA of other joints.
Formulary status
The Drug Advisory Committee (DAC) recommended that intraarticular (IA) injections of viscosupplements not to be listed on any WSIB formulary. The WSIB accepts the DAC recommendation.
Recommendation highlights
- Hyaluronic acid (HA) is a naturally occurring mucopolysaccharide present in the connective tissue of all animals. HA functions as a viscoelastic support to maintain separation between tissues, as a tissue and joint lubricant.
- Systematic reviews and meta-analyses of randomized controlled trials for treatment of knee OA suggest modest short-term reductions in pain and improvement in function that are of questionable clinical significance. The evidence to support improvements in quality of life is insufficient. A high degree of heterogeneity exists in study populations, study designs, tested products, administration techniques, dosing regimens, clinical outcome measures and responses which limits ability to draw conclusions.
- There is no evidence suggesting any difference between viscosupplement products and formulations in terms of safety and efficacy.
- Clinical practice guideline recommendations are conflicting, with some guidelines recommending a trial of viscosupplements if other options fail to address knee OA pain and others not recommending use.
- Evidence supporting the use of IA HA for joints other than knee is very limited and use is not recommended in the literature.
- Administration of HA in knee OA is considered safe with a possible side effect of local inflammation that is transient and usually resolves on its own.
- There is limited cost-effectiveness evidence to support the use of IA HA. The majority of pharmacoeconomic studies were either not applicable to the Canadian setting or were industry sponsored.
- The Province of Ontario does not cover viscosupplements due to poor evidence of efficacy.
- Therefore, the DAC concluded there is little evidence to indicate any therapeutic or non- therapeutic advantage of IA HA injections over appropriate comparators in the treatment of OA of knee.
Drug profile
Products available in Canada:
- Cingal®, orthovisc®, monovisc®, durolane®, durolane SJ®, euflexxa®, synvisc®, synvisc one®, hyalgan®, suplasyn®, suplasyn MD®, synolis V-A®, neovisc®, go-on®
- Viscosupplement products containing hyaluronic acid or its derivatives are currently licensed by Health Canada in accordance with the Medical Devices Regulations.
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