Osteoarthritis (OA) is a widespread degenerative joint disease causing significant pain, stiffness, and functional limitation for millions globally. When conservative measures like analgesics and physical therapy prove insufficient, intra-articular injections become a valuable treatment option. Cingal®, developed by Anika Therapeutics, offers a unique single-injection approach by combining cross-linked hyaluronic acid (HA) with a corticosteroid, triamcinolone hexacetonide (TH).

This article provides a clinical overview of Cingal injection, detailing its composition, dual mechanism, established applications (primarily knee OA), considerations for other joints like the hip, injection technique principles, and crucial safety information for practitioners utilizing this combination therapy.

Understanding Cingal®

Cingal® is distinguished by its combination of two active components within a single syringe:

• Hyaluronic Acid (HA) Component: Cingal contains cross-linked HA (often at a concentration around 88mg/4ml). This non-animal origin HA acts as a viscosupplement, aiming to restore the lubrication, shock absorption, and viscoelastic properties of the synovial fluid within the joint. This can help improve joint function and reduce pain over time.
• Corticosteroid Component: Contains Triamcinolone Hexacetonide (TH), a potent, long-acting corticosteroid (often at a dose of 18mg/4ml). TH functions as a powerful anti-inflammatory agent, reducing inflammatory mediators and cytokine activity within the joint space. This leads to a rapid decrease in pain and swelling.

The rationale behind this combination (the hyaluronic acid steroid combination) is synergistic. The TH provides relatively immediate pain relief, bridging the gap until the viscoelastic and potential biological effects of the HA become more apparent. The HA component may then provide more sustained, longer-term support than a steroid injection alone, addressing the mechanical aspects of OA. This represents a viscosupplementation steroid synergy approach to OA treatment.

Clinical Applications & Patient Selection

Cingal®’s primary established clinical application is for symptomatic relief in patients with knee OA:

• Primary Indication (Knee OA): Cingal® is approved and widely used in many regions for relieving pain associated with osteoarthritis of the knee. Clinical studies support its efficacy in reducing pain and improving function in appropriately selected patients.
• Hip OA & Other Joints (Off-Label Context): Practitioners may consider using Cingal® for other joints affected by OA, such as the hip. This application is often considered off-label in many regions, guided by clinical judgment and extrapolation of data from knee studies and general knowledge of intra-articular injection for OA in these joints. While the disease process is similar, it is important to acknowledge the relative lack of extensive, large-scale clinical trial data specifically for Cingal® in the hip compared to the knee. Its use in the hip is based on the rationale that both components may be beneficial in this context, but requires careful patient counseling regarding its regulatory status for that specific joint.

Patient Selection Criteria:

• Ideal Candidates: Patients with symptomatic mild to moderate OA in the target joint (knee, potentially hip) who have not achieved sufficient relief from more conservative therapies (e.g., oral analgesics, physical therapy). Patients seeking both relatively rapid pain relief and potentially sustained improvement.
• Contraindications: Contraindications must be thoroughly reviewed as per the product guidelines. These typically include known hypersensitivity to HA, TH, or any component of the product (check HA origin for potential avian protein allergy if applicable). Active joint infection (septic arthritis) or skin infection at the injection site are absolute contraindications due to the severe risk of exacerbating infection. Systemic infections or bleeding disorders may also be contraindications or require caution. Caution may be advised in patients with poorly controlled diabetes due to the potential for the steroid component to transiently affect blood glucose levels.

Administration Technique: Emphasis on Safety & Accuracy

Strict adherence to aseptic technique for all intra-articular injections is paramount to prevent the devastating complication of septic arthritis. The approach varies by joint:

• General Principles:
  • Aseptic Technique: Prepare the injection site meticulously using sterile technique (surgical scrub, sterile gloves, single-use sterile needles/syringes).
  • Single Joint: Cingal® is intended for injection into only one joint per treatment cycle.
  • Product Handling: Store at room temperature. Gently mix or invert the syringe if specified in the product guidelines before use, but avoid shaking.
• Knee Injection: Standard approaches like the superolateral approach into the knee joint space are typically used. Confirming correct needle placement is important before injecting the full 4ml volume.
• Hip Injection (ADVANCED TECHNIQUE): Due to the depth of the hip joint, its complex anatomy, and the close proximity of major neurovascular structures (femoral nerve, artery, and vein), accurate intra-articular hip injection requires image guidance. Ultrasound guidance is commonly used for real-time visualization of needle placement. Fluoroscopy may also be used. Blind hip injections are generally considered below the standard of care due to the high risk of extra-articular injection or injury. Common approaches under guidance include anterior or lateral approaches. Confirmation of intra-articular placement (e.g., by observing joint capsule distension with a small amount of anesthetic or saline) before injecting Cingal® is essential.

Post-Injection Care & Expected Course

Advise patients on standard post-injection care:

• Immediate Aftercare: Recommend relative rest of the joint for 24-48 hours following the injection. Avoid strenuous activity or heavy weight-bearing immediately. Ice application as needed can help with transient post-injection pain or swelling.
• Expected Timeline: Patients may experience rapid relief of pain and swelling within days, attributable primarily to the steroid component. This relief is then potentially sustained for months, attributed to the combined effect of TH and the viscosupplementation provided by the HA. Longevity of relief is commonly cited around 6 months but is variable between individuals.
• Follow-up: Monitor patients for efficacy and any potential adverse events at follow-up appointments.

Safety Profile, Potential Side Effects & Risk Management

While generally well-tolerated, practitioners must be aware of potential side effects and, critically, serious risks:

• Common Side Effects: Transient increase in pain, swelling, or joint effusion immediately following the injection is common. Local site reactions like redness or bruising may occur.
• Steroid-Specific Effects: A “post-injection flare” (transient increase in pain/inflammation, sometimes hours after injection) can occur; typically resolves within 24-48 hours. Triamcinolone can cause transient, usually minor increases in blood glucose in diabetics. Local skin changes (atrophy, hypopigmentation) are rare with intra-articular TH but possible with superficial leakage.
• HA-Specific Effects: Rare inflammatory reactions (pseudo-septic reactions) have been reported with HA products.
• Serious Risks (CRITICAL):
  • Septic Arthritis: Infection within the joint space is a devastating, though rare, complication requiring immediate diagnosis and aggressive treatment (IV antibiotics, joint lavage). Strict adherence to aseptic technique is the single most important preventative measure.
  • Neurovascular Injury: Particularly relevant for hip injections if guidance or technique is flawed, given the proximity of major vessels and nerves. Can lead to severe complications.
  • Severe Allergic/Hypersensitivity Reactions: Although rare, preparedness for anaphylaxis is necessary with any injectable product.

Practitioners must be prepared to recognize and manage these side effects and complications promptly.

Regulatory Status & Sourcing Authentic Cingal®

Cingal® is approved for use in numerous countries globally. Practitioners MUST ensure that Cingal® is approved and legally permissible for use in their specific region and for the intended indication (e.g., knee OA). Regulatory approval status and specific approved indications may differ between countries. Obtaining authentic Cingal® is essential for safety and efficacy. Source only from authorized distributors or reputable licensed suppliers like Health Supplies Plus to guarantee product quality, sterility, and correct formulation. Be vigilant against counterfeit products.

Conclusion

Cingal® offers a unique single-injection combination of hyaluronic acid and triamcinolone hexacetonide, providing a dual mechanism targeting both the mechanical and inflammatory aspects of osteoarthritis pain. While its established use is primarily for knee OA, experienced practitioners may consider its potential application in other joints like the hip, acknowledging this is often off-label and requires strict adherence to safety protocols.

Successful use depends critically on appropriate patient selection, meticulous sterile technique, accurate injection technique, awareness of potential risks, and sourcing authentic product. When used appropriately and safely, Cingal® is a valuable option in the management of OA symptoms.

Doris Dickson

About the Author: Doris Dickson is a specialist writer for Health Supplies Plus, focusing on the aesthetic medicine industry. She diligently researches cosmetic treatments and products to provide clear, concise information relevant to licensed medical professionals. Her work supports Health Supplies Plus’s commitment to being a reliable informational resource and trusted supplier for the aesthetic community.

 

Disclaimer: The content provided in this article is intended for informational purposes only and is directed towards licensed medical professionals. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment, nor does it constitute an endorsement of any specific product or technique. Practitioners must rely on their own professional judgment, clinical experience, and knowledge of patient needs, and should always consult the full product prescribing information and relevant clinical guidelines before use. Health Supplies Plus does not provide medical advice.