Is PRP, aka platelet rich plasma, better than cortisone and hyaluronic acid for knee arthritis?
PRP or platelet rich plasma has been around since the 1970s. It wasn't until the past several years that it has started to gain traction as a viable treatment option of arthritic conditions. Science and medicine sometimes move at a snail's pace. On one hand, this good to ensure that we have evidence to support the best outcomes and safety, but on the other hand it can slow down progress limiting potentially therapeutic treatment options for patients that would benefit now. Fortunately, we have finally crossed the threshold of evidence needed to show that PRP is safe and effective for a number of conditions, the most common being arthritis.
What is PRP?
Simply put, PRP is harnessing the repair mechanisms in our body and directing them where they otherwise cannot effectively get to. PRP is a concentration of growth factors, cellular signals and messengers to promote regeneration and repair while also turning down the inflammation pathways which can lead to pain and cell death. An oversimplified example would be when you cut your arm, you will bleed and form a clot. That clot is compromised mostly of platelets bound to fibrin. When bound they release granules that are loaded with growth factors in addition to that amber colored plasma that also has growth factors. Fast forward a few days and the cut is healed up. We take it for granted but that is a very complicated process when you think of all the tissues that are to be repaired from a simple cut. The layers of skin, nerves, vessels, hair follicles, sweat glands, etc. It is a miracle that we take for granted. It makes sense for us to take that restorative power and direct it to where it otherwise cannot get to. Joints and tendons do not have a great blood supply. If they did, we would constantly be bleeding in our joints and tendons with pressure and movements, as those vessels are fragile. We now have a safe and effective way to overcome that limitation.
Evidence for PRP
There have been a number of randomized controlled trials revolving around the use of PRP, and most have shown it to be effective when compared to cortisone (a steroid), hyaluronic acid and of course, placebo. Recently, the American Journal of Sports Medicine published a systemic review/meta analysis looking at the efficacy of intra-articular injections of the knee. The analysis included studies that used hyaluronic acid, corticosteroids, PRP, and PRGF (platelet rich growth factors) which is a derivative of PRP, and placebo. The end result showed that PRP yielded improved outcomes using pain and function scores compared to the other options after a minimum 6 months of follow up. Additionally, there are several randomized placebo controlled trials and trials comparing PRP head to head to cortisone or hyaluronic acid with PRP coming out ahead.
An honest appraisal of the evidence clearly shows PRP to be beneficial for those suffering with arthritis. Generally speaking, the mild and moderate arthritis tends to respond the best with positive effects lasting the longest, sometimes more than a year. It has also shown to be of benefit even in those with advanced arthritis.
Treatment Options for Arthritis
The point of all of this is that it is now time to reframe how we think of our traditional treatment options when it comes to arthritis. The medical community and the greater society to an extent, will accept NSAIDS with their risk of bleeding and kidney injury, cortisone with its known risks to diabetes, further acceleration of cartilage destruction, localized fat atrophy, and impaired immune and healing responses, and hyaluronic acid which can be cytotoxic (causes cell death), lead to infections and allergic reactions, and is very expensive for only temporary relief for the few that get it. We even accept arthroscopy and replacement as standard care and acceptable. To be fair, arthroscopy for arthritis (cleaning up the joint), is now falling by the wayside due to research showing that it really doesn't prevent or even delay replacement in most cases, while being an invasive, expensive alternative. Next, we have joint replacements, but somehow we don't even blink at the rates of infection, post op complications, rates of the replacement needing replaced, as well as the decreased quality of life and limitations after the replacement that many suffer and we unaware of beforehand. Some trade one pain for another due to nerve and tissue damage as well as scarring. According to Blue Cross Blue Shield Association, the average cost of a knee replacement without complications, was over $31, 124, and even as expensive as $69, 654 in New York.
Contrast that with PRP that has been shown to be safe. It has been shown to be effective. It has even been shown to have antibiotic properties. It is a safe, effective, and natural treatment in the emerging field of regenerative medicine. It is also much less expensive than many alternatives, ranging from $500-$1500. Why then, at a minimum, have we not added this for equal consideration to our treatment armamentarium? Do we not have a moral imperative to offer PRP to those patient's suffering from arthritis. They deserve better.