Viscosupplements: Uses, common brands, and safety info

Viscosupplements are an intriguing but controversial option for treating knee arthritis. Osteoarthritis of the knee is incredibly common, affecting 22% of individuals aged 40 and older. Medical treatment options of knee osteoarthritis (OA) are quite limited, leading many to need physical therapy or surgical treatment. Over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are often tried, and prescription NSAIDs may be substituted. These all incur some risk and provide limited, short-term benefit. Intra-articular (joint) injections may be offered next in an attempt to relieve pain and improve function.

Intra-articular corticosteroid injections have long been used for their strong anti-inflammatory effect. When steroid injections are not tolerated or fail to help, viscosupplement injections are sometimes used in an attempt to delay or avoid knee replacement surgery. However, they are not universally recommended by different orthopedic experts. We will explore the reason why and review the types, mechanisms of action, adverse effects, and costs of viscosupplements.

What are viscosupplements?

Viscosupplement injections deliver hyaluronic acid to the joint space. The hyaluronic acid products come in three major forms, sodium hyaluronate, hylan gf-20, and high molecular weight hyaluronan. The drug administration is done as a single or series of injections into the knee joint by a healthcare professional, usually either in a primary care, orthopedic, or rheumatology office.

How do viscosupplements work?

Osteoarthritis is the most common arthritis in the United States and is marked by degeneration of the smooth cartilage surfaces within joints and counterproductive enlargement of bony and soft tissue components of joints. While rheumatoid arthritis is a more inflammatory arthritis that’s attributable to inflammatory cell activity, osteoarthritis has excessive inflammation primarily related to protein mediators.

Hyaluronic acid is naturally present within joints. According to a recently published review of viscosupplements, it is a major contributor to the viscosity of synovial fluid, the liquid substance within joints. Hyaluronic acid also offsets pro-inflammatory mediators within the joint. These dual actions are a major reason why supplementation of hyaluronic acid has held such promise for osteoarthritis pain relief and functional improvement. The theory being that by bolstering synovial fluid’s ability to be a lubricant and shock absorber, as well as being an anti-inflammatory within the joint, hyaluronic acid supplementation could offer significant benefit in the setting of knee osteoarthritis.

Studies have shown reduced knee pain, less stiffness, and improved quality of life with viscosupplements. Other clinical trials have not always corroborated those findings. Meta-analysis and reviews of multiple studies have come to different conclusions about the benefits of viscosupplementation treatment of osteoarthritis of the knee. For these reasons, some orthopedic experts and groups do not recommend this drug class.

What are viscosupplements used for?

• Osteoarthritis of the knee

Types of viscosupplements

Sodium hyaluronate

The salt form of hyaluronic acid is a naturally occurring joint substance that lubricates and cushions the joint, while mitigating inflammation. Like many of the viscosupplements, Supartz Fx is derived from chicken combs, a fact that has led them to be called “rooster shots.”  The product is given as a series of three to five weekly injections. Other varieties, Euflexxa and Gelsyn-3 are given as a three shot series as well, but Durolane provides a one injection option. The sodium hyaluronate in Durolane is cross-linked, increasing its durability within the joint enough to permit single dosing.

Hylan gf-20

Synvisc is brand-name hylan gf-20 and is another cross-linked hyaluronic acid variety. It also has a higher molecular weight than other hyaluronic acid products, which may add to its durability and viscosity contribution. A three-dose series of injections normally, Synvisc is also produced as Synvisc-1 to allow a single-dose treatment regimen.

High molecular weight hyaluronan

Other high molecular weight viscosupplements include Monovisc and Orthovisc. As its name implies, Monovisc is a one-time injection of hyaluronic acid. Orthovisc, on the contrary, is given three or four times.

Who can take viscosupplements?

Can men take viscosupplements?

Men can receive viscosupplement intra-articular injections.

Can women take viscosupplements?

In addition to obesity and age, female gender is a risk factor for knee osteoarthritis, and women can receive hyaluronic acid injections if needed.

Can you take viscosupplements while pregnant or breastfeeding?

No adverse effects are known from using viscosupplements during pregnancy or breastfeeding, but clinical trials evaluating for possible risk are limited. Accordingly, caution is advised before receiving the injections in these circumstances.

Can children take viscosupplements?

Viscosupplements are not approved for use in children.

Can seniors take viscosupplements?

Based on their higher incidence rates of osteoarthritis, seniors have a need for and can receive viscosupplementation injections.

Are viscosupplements safe?

Black box warnings

The FDA does not have its highest degree of warning on viscosupplements.

Recalls

There are no current recalls for viscosupplements, but for the most recent information, search for updates on the FDA’s database.

Restrictions

Anyone with a history of hypersensitivity allergic reactions to a viscosupplement drug or the class should not use them. Infections and skin diseases at the proposed site of intra-articular hyaluronic acid injection are other contraindications to its use.

Are viscosupplements controlled substances?

Viscosupplements are not listed by the Drug Enforcement Administration (DEA) as controlled substances.

Common viscosupplements side effects

• Joint pain

• Joint swelling

• Injection site pain

• Back pain

• Headache

How much do viscosupplements cost?

In addition to the cost of the healthcare provider who is injecting the medication, the viscosupplement shots alone are expensive. The cost is typically more than $1,000 for a treatment course, whether that means one injection or follow-up injections. Getting a SingleCare discount card can help make them more affordable, so show your card to the pharmacist.