• Abstract 1826: Intra-articular Corticosteroid Injection of the Thumb in OA
• Abstract 1823: Relationship Between COX-2 Inhibitors and Myocardial Infarction

Abstract 1826 Intra-articular Corticosteroid Injection of the Carpometacarpal Joint of the Thumb in Osteoarthritis
GK Meenagh, J Patton, C Kynes, GD Wright

Osteoarthritis has a predilection for several different joints in the appendicular skeleton, including the hip, knee, distal and proximal interphalangeal joints, and the 1st carpometacarpal joint of the thumb. The thumb CMC joint, however, has been the subject of relatively little study compared to the other joint groups, in terms of efficacy of current therapeutic strategies. Nevertheless, osteoarthritic changes at the base of the thumb do result in substantial morbidity and impairment in activities of daily living.

In order to rigorously evaluate the therapeutic benefit associated with steroid injection to this joint site, Meenagh et al performed a prospective randomized double-blind controlled trial. Patients were randomized to receive either intra-articular injection of triamcinolone or sterile water by a second blinded investigator. At baseline each subject had a full clinical assessment by a blinded investigator. This included analgesic intake in the last week for thumb base pain, physician global assessment (PGA), patient global assessments (PtGA), and patient visual analogue pain score (VAS). The injection procedure was carried out under radiological guidance to ensure accuracy. The thumb was immobilized in a thumb spica splint in both groups for a period of 48 hours. Clinical assessments were repeated at 4 weeks, 3 months and 6 months following injection.

Results: Twenty patients were randomized to each arm of the trial. At baseline, clinical assessments and osteoarthritic changes visualized radiographically were similar in the two groups. During follow-up, the steroid arm of the trial showed no significant difference in PtGA, VAS and analgesic intake between baseline and 24 weeks. Similar results were found in the placebo group. In contrast, physician global assessment in the steroid group did show significant improvement compared to the placebo group. It appears that this trial revealed no appreciable benefit in the eyes of the patient participants, both in terms of pain and global assessment. In contrast, the doctors involved in the trial did perceive benefit associated with steroid injection.

Editorial Comments: The results of this trial point in opposite directions depending upon ones status as participating patient or treating physician. Whereas there was no apparent benefit by patients from steroid injection of the CMC joint of the thumb, there was significant improvement in physician global assessment with steroid injection. It is notable that the patient population in this trial did have moderately severe radiographic change at baseline and this may have exerted influence over the response to steroid injection. It is possible that those patients with mild or moderate osteoarthritic changes at the 1st CMC joint would stand to reap greater benefit from steroid injection, in contrast to the patients with more advanced radiographic changes seen in this study.

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Abstract 1823 The Relationship Between Selective COX-2 Inhibitors and Acute Myocardial Infarction
DH Solomon, S Schneeweiss, RJ Glynn, Y Kiyota, CC Cannuscio, R Levin, H Mogun, J Avorn

Since the arrival of COX-inhibitors only a few years ago, the volume of their prescription has exploded in the American population. Two years ago, however, concern was raised in that these agents may have a deleterious side-effect, in terms of heightened cardiovascular morbidity that may offset their improved gastrointestinal profile.

To further address this timely question, Solomon et al examined the risk of heart attacks (acute myocardial infarctions) associated with celecoxib and rofecoxib, the first two coxibs (or COX-2 inhibitors) introduced to market. Using a case-control study design, the investigators analyzed data from 54,475 patients > 65 years of age who received their medications through two state-sponsored pharmaceutical benefits programs in the United States. The development of myocardial infarction was identified by review of health care utilization encounters.

Results: The investigators found that rofecoxib was associated with a heightened risk, in the range of 10-20% increase in risk when compared to those prescribed celecoxib or no NSAID at all. This heightened risk was also observed when the cardiovascular profile for those prescribed rofecoxib was compared to those receiving naproxen or ibuprofen, two commonly used non-selective NSAID agents. In this latter comparison, however, the heightened risk was not statistically significant. Of note, the adverse risk of acute MI associated with rofecoxib was greatest at the highest doses (> 25 mg per day of rofecoxib) and during the first 90 days of new rofecoxib use. Celecoxib, in contrast to rofecoxib use, was not associated with this heighten risk profile.

Editorial Comments: These findings are certainly intriguing, and lend further support to exercise caution when considering issuance of a prescription for rofecoxib, particularly among those patients at heighten risk of cardiovascular morbidity.

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