Effect of premedication with intra-articular hydrocortisone on the retention of 198Au in the knee joint in rheumatoid arthritis. Use of 99mTc in assessment.

Intra-articular radioactive colloids are most often used to treat rheumatoid arthritis of the knee when joint effusion persists in one or both joints after general measures and simple local measures have failed. Almost certainly an intra-articular steroid will have been tried. Even when long-term help is not obtained by intra-articular steroids, there is usually temporary subjective benefit and often objective evidence of reduced activity. When I first premedicated knee joints with hydrocortisone 4 years ago I considered two possible advantages from even such transient benefit. One was that it might eliminate any reactive inflammation to colloidal radioactive gold. I believe Delbarre, Cayla, Aignan, Roucayrol, Menkes, and Ingrand (1968) used intra-articular steroids at the same time as colloidal radiogold for this purpose, and also for clearing the needle of radioactive material. The other possible advantage was that, by reducing the effusion and perhaps the thickness of the synovium, the short range f-emission of the colloidal gold would be more effective. Subjective improvement from intra-articular steroids may take up to 2 days or more to reach its maximum. If joints are aspirated at intervals after injection with intra-articular steroids, change in the joint fluid occurs over 2 or 3 days, with the fluid gradually becoming clearer and more viscid. From these clinical observations, an interval of 2 or 3 days seemed desirable between the premedication with intra-articular hydrocortisone and the administration of the radioactive colloid. Long after the synovial fluid has reverted to its previous cloudy watery state, subjective benefit may continue, so that objective criteria are needed to judge the optimal interval. The first four patients treated in this way had bilateral knee effusions. 50 mg. (25 mg. in one case) hydrocortisone for intra-articular use was injected into one knee of each patient, and 2 days later 10 mCi. colloidal radioactive gold (particle size 20-30 m,) was given by intra-articular injection to both knees. Scans of the groins and abdomen 3 to 8 days later showed no leakage to the inguinal, para-iliac, or para-aortic glands on the sides which had received premedication, but three out of the four sides not premedicated showed leakage to the glands. It was purely serendipity which revealed that premedication with hydrocortisone reduced the leakage of colloidal radioactive gold. Subsequently we looked into this question alone and tried to find the optimum interval between premedication and therapeutic injection by varying the interval. Standard premedication was used with 50 mg. hydrocortisone. Some knees were not premedicated. In this paper, 'leakage' means any loss of radioactivity to inguinal, pelvic, or intra-abdominal glands as shown on scans mainly done between 1 hour and 2 days after the radioactive gold was injected. No attempt was made to assess grades of leakage. 52 knees (28 patients) gave the results shown in Table I. All the patients had rheumatoid arthritis and most were seropositive. There were ten men and eighteen women. All but one were over 50 years of age, most of them being over 60. One woman had both knees treated in 1969 and again in 1972.