Viscosupplements as an alternative to steroid injections for immuno-compromised patients

Clinician checks patient's knee   

Newly published NHS England guidelines (16 March 2020), regarding the management of trauma and orthopaedic patients during the Coronavirus pandemic, highlight the need for a shift towards non-operative care as the system comes under ever-increasing pressure.1 During this period of heightened burden, MSk patients with degenerative or traumatic changes to articular joints must be adequately cared for, and while treatment strategies are being revised – with more conservative management and the deferral of orthopaedic elective surgery being recommended – the delivery of appropriate therapeutic options directed to the patient’s symptoms remains essential. 

Many UK NHS Trusts have enforced a moratorium on intra-articular (IA) corticosteroid (CS) injections due to the associated and well-elucidated post-injection immunosuppressive effects.2 CS serves to interrupt inflammatory and immune cascades, decreasing capillary permeability and vascularity and binding to glucocorticoid receptors, resulting in complex changes to gene transcription - inhibiting accumulation of inflammatory cells and mediators.3 Whilst CS may prove markedly effective in the management of inflammatory and autoimmune disorders,  such inhibitory effects on multiple types of immune cells, especially in vulnerable patients,  presents clinicians with a quandary during the current COVID-19 pandemic – and the challenge to offer a viable alternative. 

Viscosupplementation (Intra-Articular Hyaluronic Acid (HA)) offers patients and clinicians a non-immunosuppressive, physiologic treatment option for joint pain and loss of function; crucially, eliminating any concern over further jeopardising immuno-compromised patients. IAHA negates other risks and contraindications associated with IACS usage including such localised effects as: chondrotoxicity, cartilage damage, post-injection flare, subcutaneous tissue atrophy and systemic effects such as flushing, osteoporosis, and hyperglycaemia - a serious consideration in patients with diabetes mellitus.4,5 Viscosupplementation offers a safe and effective treatment option for patients suffering degenerative joint pain and loss of function. If conservative treatment and/or pharmacological management has failed to adequately resolve symptoms, and in accord with the current advice whereby corticosteroid injection is proscribed in immuno-compromised patients, Viscosupplementation should be considered as the preferred mode of injection therapy. 

Here is a summary of Statements and Guidance by the NHS and other organisations: COVID-19 and Corticosteroid Joint Injections: Position Statements and Guidance

Please also see this statement by BSSR (British Society of Musculoskeletal Radiologists):


Additional Consideration Around Corticosteroid Injections During COVID-19 Pandemic

The withdrawal of CS injections - or agents containing CS- should certainly be given serious consideration by all clinicians during the current COVID-19 pandemic6.  Novel virus pandemics have historically manifested a primary and then secondary peak phase 2. 
The second peak may see the virus mutate into a more deadly strain and become a lot more dangerous – as was seen in the Spanish Flu pandemic (Fig.1)7,8. Those who contracted the initial strain during the first peak - and subsequently survived - largely acquired immunity. Those who didn’t faced a much greater magnitude of mortality risk. The number of UK deaths in the second wave was almost 5 times that of the number of deaths seen in the initial wave.

Spanish Flu deaths by month
Fig. 1: Three pandemic waves: weekly combined influenza and
pneumonia mortality, United Kingdom, 1918–1919.


If patients in vulnerable groups are having a CS joint injection around the time of the second peak – should that pandemic profile emerge - then the magnitude of risk around any steroid-induced immuno-suppression may be significantly increased1. The potential implications are that the immunosuppressive effect of CS injections, combined with the possibility of a second peak, combined with the fact that many patients who receive CS joint injections have co-morbidities which may be exacerbated e.g. Diabetes Mellitus, suggests that for the short and medium term, clinicians should give very careful consideration to routinely administering CS injections,  and consider other options for treating degenerative or traumatic join pain such as Viscosupplementation.

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  2. Oppong, E. and Cato, A., 2015. Effects of Glucocorticoids in the Immune System. Advances in Experimental Medicine and Biology, pp.217-233.
  3. Ayhan, E., 2014. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World Journal of Orthopedics, 5(3), p.351.
  4. Honcharuk, E. and Monica, J., 2016. Complications Associated with Intra-Articular and Extra-Articular Corticosteroid Injections. JBJS Reviews, 4(12), p.1.
  5. Choudhry, M., Malik, R. and Charalambous, C. (2016). Blood Glucose Levels Following Intra-Articular Steroid Injections in Patients with Diabetes. JBJS Reviews, 4(3), p.1.
  6. Sytsma, T.T., Greenlund, L.K. and Greenlund, L.S., 2018. Joint Corticosteroid Injection Associated With Increased Influenza Risk. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(2), pp.194-198.
  7. 2020. Spanish Flu. [online] Available at: <> [Accessed 23 March 2020].
  8. Tumpey, T.M., Basler, C.F., Aguilar, P.V., Zeng, H., Solórzano, A., Swayne, D.E., Cox, N.J., Katz, J.M., Taubenberger, J.K., Palese, P. and Garcia-Sastre, A., 2005. Characterization of the reconstructed 1918 Spanish influenza pandemic virus. science, 310(5745), pp.77-80.