Cingal Injections: Dual-Action 2x as Effective?

Cingal – Treatment Potency Rating (TPR)

We have developed a bespoke treatment scoring system called Treatment Potency Rating (TPR) which allows you to preview how efficacious each treatment is, at a glance.

This is our Treatment Potency Rating (TPR) of Cingal in a table format:

Cingal Rating:	7.8 / 10.0
How it works? (Mechanism of Action, MoA):	Supplements the joint & anti-inflammatory.
What proof is there? (Evidence For Efficacy):	Clinical trials and anecdotal reports.
Date to market? (Longitudinal Data):	Since 2016.
Risks? (Side Effect Profile):	Mostly mild. Possible redness, slight swelling.
Treatment Duration:	1 injection, but may need repetition.
Recovery Time:	Minimal. A day, or less than a week.
Cost-effectiveness:	A bit more expensive, but more effective.
Provider Expertise:	Moderate expertise is required.
Best Suited For:	Osteoarthritis (OA).

What Are Cingal Injections?

Cingal is just the brand name for an injection-based, osteoarthritis (OA) medication.

Released in 2016, it is the first treatment to pre-mix and combine – two proven active ingredients into a single injection (1).

1. Hyaluronic Acid (HA) – highly concentrated, cross-linked, non-animal based, produced from bacterial fermentation.
2. Triamcinolone Hexacetonide (TH) – a powerful corticosteroid.

The hyaluronic acid lubricates and cushions the joint. Providing lasting pain relief and reduction in joint stiffness. This is also known as viscosupplementation and in the case of Cingal, it can last up to 6 months.

Whereas the corticosteroid quickly reduces the pain and inflammation, offering immediate relief to the affected area.

We’ve noticed most patients experience rapid, “miracle-like” pain relief within the same day of the injection. However, this is dependent on the severity of osteoarthritis.

The more severe, the less “miracle-like” it would feel.

Nonetheless, even in the worst cases, you can still experience tremendous same-day relief lasting up to 1-2 or more months.

This dual synergistic approach targets both the symptoms and underlying causes of osteoarthritis.

Therefore, Cingal creates a so-called “1+1=3” effect.

Where each active ingredient on its own contributes only by 1. But both combined together, potentiate each other, to enhance the overall beneficial effect.

There’s additional independent clinical data (unrelated to Cingal) comparing Hyaluronic Acid (HA) monotherapy vs Hyaluronic Acid (HA) + Corticosteroid. The evidence showcased HA + Corticosteroid injections were more effective in decreasing pain and improving physical function than standalone HA. But standalone HA was also effective, just to a lesser degree (2).

But we advise you not to rush your decision because there are other treatments which have different mechanisms of action. And some might be more befitting to your specific case.

To learn more about these different options, check the Alternatives section by (clicking here).

Cingal Injections for Hip or Knee Pain

As we discussed in Section 1 of this article, Cingal Injections can produce immediate, “miracle-like” pain relief.

This is mainly due to the powerful corticosteroid Triamcinolone Hexacetonide (TH), which rapidly reduces inflammation and swelling.

Therefore, if you’re suffering from hip or knee joint pain due to osteoarthritis, Cingal’s viscosupplemental and anti-inflammatory properties can be highly effective and generally safe.

We’ve also seen patients online asking whether Cingal can be used for meniscus repair.

It may offer symptomatic relief in cases where osteoarthritis symptoms overlap with those from a meniscus injury.

However, Cingal’s role in meniscus repair isn’t established and is indirect at best. Healing a damaged meniscus typically involves physical therapy to strengthen the muscles around the knee and improve flexibility. In some cases, surgical intervention may be necessary to repair or remove the torn portion of the meniscus.

Triamcinolone Hexacetonide has a good safety profile underpinned by a lot of empirical evidence.

Unlike, other corticosteroids used in joint injections, such as triamcinolone acetonide, TH has lower water solubility (3).

This prevents it from being absorbed by the body too quickly, thereby remaining inside the target joint for longer.

It can continue providing anti-inflammatory support while resulting in lower systemic glucocorticoid levels (4).

When dealing with injectable corticosteroids, we want to avoid increasing systemic glucocorticoid levels because this can increase the risk of side effects.

That’s why Triamcinolone Hexacetonide (TH) is generally safer – it remains in the target joint for longer, offering localised benefits while reducing systemic exposure.

Cingal vs Cortisone

Both Cingal and Cortisone injections are viable options for joint pain and osteoarthritis.

As mentioned above, Cingal is a composite, pre-filled syringe of 4 ml. It uniquely combines Triamcinolone Hexacetonide (TH), a long-acting corticosteroid, with hyaluronic acid (HA). TH provides immediate anti-inflammatory and pain-relieving effects. Whereas HA targets one of the root causes of osteoarthritis. It replenishes the synovial fluid of the joint, improving function and alleviating pain long-term.

Cortisone, on the other hand, is just a corticosteroid without the addition of HA. In layman’s terms, it’s like Cingal but without the lubricating effects of Hyaluronic Acid. For this reason, cortisone injections are primarily used to reduce inflammation and pain.

So the question is – which corticosteroid is better Triamcinolone Hexacetonide (TH) or Cortisone?

If we assume that both are dosed equally, TH is generally considered to be more potent.

Triamcinolone Hexacetonide has a higher binding affinity for the receptors in the cytoplasm of the target cell (5).

Meaning that it interacts more effectively and for a longer duration with these receptors, leading to a stronger anti-inflammatory effect.

This potency makes it particularly effective for managing severe inflammation in joint conditions such as osteoarthritis.

Cortisone, while effective, is considered less potent than TH. It’s often used for milder conditions or in situations where a less potent steroid is preferred due to the patient’s overall health, potential side effects, or specific clinical goals.

Therefore, in theory, Cingal’s mechanism of action is superior, since you’re getting the longer-lasting beneficial effects of HA with the rapid pain reduction of a more potent corticosteroid.

But there are scenarios where a patient might wish to not get Hyaluronic Acid, therefore they can opt-in for a standalone Cortisone shot. Such scenarios are:

• Allergies or Sensitivities: Some patients might be sensitive or allergic to HA or components used in HA formulations. In such cases, to avoid allergic reactions, a standalone corticosteroid injection without HA would be preferred.
• Cost Considerations: Treatments that include HA can be more expensive than those that only contain corticosteroids. Patients or healthcare systems with limited budgets might opt for the less expensive option, especially if the primary goal is to quickly reduce inflammation.
• Prior Lack of Response to HA: Patients who have previously received HA injections without significant improvement in their symptoms might choose to try a different treatment approach. A standalone corticosteroid injection could provide the anti-inflammatory benefits they need without the added component that did not help in the past.
• Clinical Recommendations Based on Specific Conditions: For certain joint conditions, the primary issue might be inflammation rather than lubrication or wear of the joint. In such cases, your doctor might recommend a corticosteroid injection as the most direct approach to reduce inflammation and pain.

Cingal Injections – Price

In the UK, Cingal injection prices can range from £380 – £550+ per injection.

It mainly depends on the clinic and the injection specialist.

It’s always advisable, to choose a clinic or a specialist who has a lot of experience in intra-articular injections, i.e. joint injections.

Preferably someone who does Ultrasound-guided Cingal injections, which ensures accuracy in delivering the hyaluronic acid directly into the affected joint space.

And are Cingal Injections available on the NHS?

Unfortunately, rarely.

As per the NHS commissioning decision:

“Hyaluronic Acid injections are considered a low priority for funding and will only be considered in exceptional circumstances. Funding approval must be sought from the local integrated care board (ICB) via the Individual Funding Request process prior to treatment.” (NHS Decision)

This specific statement is taken from an NHS Gloucestershire document but is effectively the same for the entirety of the UK, and for all Hyaluronic Acid injections, irrespective of the brand name.

If you fall within these “exceptional circumstances” and manage to get Cingal via the NHS, great.

But if you wish not to waste time, it’s best to seek private treatment.

Cingal Injections – Patient Reviews

Since it was released relatively recently, Cingal isn’t as widespread as some of the more established Hyaluronic Acid injection brands.

So there aren’t many anecdotal (word of mouth) logs, but there is empirical (scientific) data backing the efficacy of Cingal.

Empirical:

What is the success rate of Cingal injections?

This double-blind, randomised clinical trial (6) compared Cingal to Monovisc and a placebo-control saline for the treatment of knee osteoarthritis.

The findings revealed that Cingal significantly improved pain and function compared to saline through 12 weeks (P = 0.0099) and continued to show significant benefits through 26 weeks (P = 0.0072).

Cingal resulted in a substantial 70% reduction in WOMAC pain score at 12 weeks, which slightly increased to a 72% reduction by 26 weeks.

“The WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) is a self-administered osteoarthritis questionnaire assessing pain, stiffness, and physical function through ranked responses, where higher scores indicate worse conditions.“

In contrast, while Monovisc also showed improvement, Cingal demonstrated superior results at 1 and 3 weeks for most endpoints. However, both treatments showed similar efficacy from 6 weeks onwards.

Thus, the study concludes that Cingal offers both immediate and lasting relief from osteoarthritis-related symptoms, significant for up to 26 weeks when compared to saline.

Anecdotal:

As for anecdotal (word of mouth) patient reviews, there are some online claiming immense overnight relief.

Which is definitely possible, since we’ve already mentioned multiple times in this article how powerful Triamcinolone Hexacetonide (TH) is.

So this overnight “miracle-like” pain alleviation is scientifically possible.

However, keep in mind that a similar effect can be achieved by manually combining Hyaluronic Acid (HA) with a Corticosteroid. A lot of practitioners and clinics prefer to manually mix other HA injection brands with their preferred Corticosteroids.

Therefore, if Cingal isn’t available in your city or region, you can achieve similar instantaneous pain relief by finding a clinic which offers combined HA + Corticosteroid injections, or just standalone Corticosteroid injections.

But remember, the efficacy will largely depend on the severity of your osteoarthritis. Like all degenerative conditions, the sooner you take action, the better of an effect you’ll have, with any treatment not just Cingal.

What to Expect During The Procedure?

Cingal injections are typically administered as an outpatient procedure and are minimally invasive.

Like all other hyaluronic acid injections, the doctor or specialist will first apply a local anaesthetic to completely numb the area.

Then they will use ultrasound to accurately guide and inject Cingal into the affected joint.

This ensures the hyaluronic acid goes exactly where it’s needed most.

Most patients typically experience minimal or no discomfort at all, during the procedure.

What to expect after a Cingal injection?

After the injection, most patients notice immediate relief (within 24 hours) mainly due to the anti-inflammatory action of Triamcinolone Hexacetonide.

While for others, the reduction in pain and improvement in joint function may develop over the following weeks.

The timeline and extent of symptom relief can vary due to the severity of osteoarthritis and other personal variables, like lifestyle, individual morphology, genetics, etc.

How many Cingal injections can you have?

The number of Cingal injections you can safely receive will be determined by your doctor, based on the severity of your condition and response to treatment. But generally, Cingal is designed as a single-injection treatment, with the possibility of repeating the procedure:

• Frequency: If symptom relief from the initial injection diminishes over time, patients may receive another Cingal injection. Usually, not before six months have elapsed.
• Limitations: While repeat injections are possible, there’s a recommended limit to the number of corticosteroid injections a patient should receive in a year. Typically no more than three to four, to minimize potential side effects.

For this reason, you should consult with your doctor to determine the appropriate treatment plan, including the need for and timing of repeat injections.

What Are The Side Effects of Cingal?

Cingal was introduced to the market in 2016 by Anika Therapeutics, Inc.

Since then it has amassed some clinical evidence regarding its safety and efficacy, but not so much anecdotal reports.

However, Cingal isn’t offering anything unproven and outlandish. It’s simply the first injection that has pre-mixed two already proven active ingredients.

1. Hyaluronic Acid (HA)
2. Corticosteroid

And both have well-established safety profiles.

But like any other medical procedure, there are potential side effects and risks.

We’ll list the side effects below. And in the next section, we’ll discuss how to minimise or eliminate them entirely.

These side effects can happen with any composite injection, mixing hyaluronic acid injection with a corticosteroid, not just Cingal.

And the side effects are mainly dependent on the skillfulness of the injection specialist or doctor.

Hyaluronic Acid (HA) side effects:

Any HA-based injectable can produce these types of adverse reactions, not just Cingal.

Common MILD side effects (10-20% of patients):

• Pain at the injection site: Some patients may experience temporary discomfort or mild pain where the injection was administered. This shouldn’t last more than 1 week.
• Swelling and redness: Minor swelling or erythema (redness) around the injection area can occur. This typically resolves on its own within a week.
• Joint and muscle stiffness: A temporary increase in stiffness at the target joint, or the muscles around it. You might notice this immediately after the procedure but it should subside within 1-2 weeks.

Rare SEVERE side effects (≤1% of patients):

• Allergic reaction: In very rare cases, patients may have an allergic reaction to the components of the HA injection. This can involve symptoms such as swelling, redness, and itching at the injection site.
• Pseudosepsis: Which combines “Pseudo” + “sepsis” = it mimics the symptoms of sepsis. Such as fever, increased heart rate, and increased white blood cell count, but does not involve a bacterial infection or actual sepsis.

Both allergic reactions and pseudosepsis are very uncommon.

Hyaluronic acid is naturally found in our joints, skin, eyes and connective tissue. It has high bio-compatibility. Therefore, when injected into the problem area, the body easily recognises and accepts it.

Extremely Rare SEVERE side effects (≤0.1% of patients):

• Infection: Like with any other injection, a needle must penetrate the skin to deliver the active ingredients. And this always carries a tiny risk of an infection. If you notice severe swelling, pain, intense warmth arising from the joint and/or fever, contact your doctor immediately.

Infections are extremely uncommon. They are more dependent on the doctor’s clinical expertise and sanitary practices than anything else.

Triamcinolone Hexacetonide (TH) side effects:

Any TH-based injectable carries the risk of these adverse effects, not just Cingal.

Common Side Effects (1-10% of Patients):

• Local reactions at the injection site – including sterile abscesses, post-injection erythema (redness), pain, swelling, and tissue necrosis.

Rare Side Effects (0.1-1% of Patients):

• Vertigo and complications due to excess dosage or too frequent administration at the same site, leading to local subcutaneous atrophy. The recovery from atrophy caused by the properties of TH may take several months.

Very Rare Side Effects (<0.01% of Patients):

• Anaphylaxis-type reactions, thromboembolism, changes in skin pigmentation (hyperpigmentation or hypopigmentation), calcinosis, and tendon rupture.

Side Effects With Unknown Frequency:

• Effects on endocrine, psychiatric, nervous, eye, cardiac, vascular, gastrointestinal, skin and subcutaneous tissues, musculoskeletal and connective tissue, and renal and urinary disorders are not known, meaning their incidence cannot be estimated from the available data.

In general, from our field observations, combined HA + Corticosteroid injections, like Cingal, offer significant and immediate pain reduction.

So our consensus, based on the empirical data we presented in this article, is that Cingal is generally safe. Most people experience either no perceivable side effects or just temporary mild redness.

However, we listed all the potential adverse reactions here, no matter how rare they are, so you can make an educated decision. Schedule a consultation with your doctor and go over the pros and cons of combined therapy.

Also, it’s important to note, that just like many other HA injection brands, Cingal shouldn’t be used in pregnant and lactating women as it’s not been evaluated in these cases.

How to Prevent Side Effects?

To prevent or minimise the risk of side effects from Cignal or any other hyaluronic acid + corticosteroid injection, consider the following:

• Ultrasound Guidance: Ensure your doctor is using ultrasound to guide the injection. As this study demonstrated (7) patients receiving ultrasound-guided knee hyaluronic acid injections were significantly less likely to undergo subsequent knee complications than patients receiving landmark-guided (physical touch, no imaging) hyaluronic acid injections.
• Treatment Quality: Ensure the Hyaluronic Acid brand your doctor uses is of high quality and sourced from reputable manufacturers, such as Cingal. Be aware of the product’s composition, as certain additives or preservatives (excipients) might increase the risk of an adverse reaction.

The full ingredients list of Cingal is:

• Hyaluronic Acid (fermentation via a proprietary bacteria strain)
• Triamcinolone Hexacetonide (a corticosteroid)
• Sorbitol
• Polysorbate 80
• Sodium Phosphate, Dibasic
• Sodium Phosphate, Monobasic
• USP water for injection q.s. to mL

The Hyaluronic Acid and Triamcinolone Hexacetonide are the active ingredients.

Whereas the remaining excipients collectively adjust the osmolarity, maintain the pH balance, protect against degradation, and keep the injection sterile.

Even though they are generally considered safe, individual sensitivities or allergies can exist. This caution is especially relevant for patients with a history of allergies to pharmaceutical excipients.

Always ask the clinic or doctor who’ll be administering any type of HA injection about the inactive ingredients. What are they? Do they pose a risk of an allergic reaction or other adverse complications?

Are There Better Alternatives to Cingal?

In terms of other brands which offer Hyaluronic Acid injections, there are quite a few.

And we have reviewed the top ones:

• Ostenil
• Durolane
• Monovisc
• Synvisc

You can view each one to learn more.

Some of these other brands might be more befitting to your needs.

So it’s difficult to say whether they are “better” than Cingal because that depends on multiple factors.

Are you looking for combined HA + Corticosteroid treatment or just standalone HA?

Remember that almost any Hyaluronic Acid (HA) injection can be manually combined with a Corticosteroid. A lot of practitioners and clinics prefer to mix other HA injection brands with their preferred Corticosteroids.

Therefore, if Cingal isn’t available in your city or region, you can achieve similar instantaneous pain relief by finding a clinic which offers combined HA + Corticosteroid injections.

Not to mention, there are numerous other regenerative treatments which have been proven to be efficacious in the treatment of osteoarthritis and other musculoskeletal problems. Such treatments are PRP, enriched PRP, nStride, Stem Cells, Arthrosamid, Goldic, Corticosteroids and more.

We have reviewed all of them meticulously. To learn more check out our Research page.

And if you’re feeling overwhelmed with all the possible treatment options, don’t be.

We can help you pick the best one for your particular condition and circumstances.

Scroll to the bottom of this article, to get bespoke guidance.

The Verdict – Is Cingal an Effective Treatment?

Cingal is quite a unique treatment, as it’s the first to formally combine Hyaluronic Acid (HA) with Triamcinolone Hexacetonide (TH) – a steroid.

Throughout the years many doctors have manually mixed Hyaluronic Acid with their preferred Corticosteroid, but Cingal is the first brand which comes already pre-mixed in a sterile environment.

This reduces the risk of contamination and offers a lot of efficiency.

However, it limits you to use the specific type of HA and Triamcinolone Hexacetonide found in Cingal.

Whereas manually compounding a composite injection allows you and the doctor to pick the best type of HA and Corticosteroid for your needs. For example, you might want a higher molecular weight HA with a less potent Corticosteroid.

But overall Cingal has sufficient clinical data and has been proven to produce immediate “miracle-like” pain relief, mainly due to how powerful of a corticosteroid TH is.

However, like any medical treatment, the outcomes can depend on several factors including:

• The severity of osteoarthritis.
• The specific joint(s) affected.
• The doctor’s level of injection proficiency and overall care.
• Is the doctor using ultrasound or landmark guidance? Preferably ultrasound.

Cingal’s synergistic dual approach does indeed offer greater efficacy. It targets both the symptoms and underlying causes of osteoarthritis.