Monovisc Injections: Different From The Rest?

Monovisc – 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 Monovisc in a table format:

Monovisc Rating:	7.3 / 10.0
How it works? (Mechanism of Action, MoA):	Supplements the synovial joint fluid.
What proof is there? (Evidence For Efficacy):	Clinical trials and anecdotal reports.
Date to market? (Longitudinal Data):	Since 2007.
Risks? (Side Effect Profile):	In most cases, minimal. Mild redness.
Treatment Duration:	1 injection, but may need repetition.
Recovery Time:	Minimal. A day, or less than a week.
Cost-effectiveness:	Relatively cheap but beneficial.
Provider Expertise:	Moderate expertise is required.
Best Suited For:	Osteoarthritis (OA).

Are Monovisc Injections Any Different?

Monovisc is the name of a Hyaluronic Acid (HA) injection brand, which shares similarities with other top contenders in this bracket.

In terms of composition, Monovisc is a single injection, high-molecular-weight, cross-linked, bacteria-derived Hyaluronic Acid treatment.

And in terms of pharmacodynamics (its effect), Monovisc supplements the synovial fluid of the joint. It lubricates and provides ‘cushioning’ thereby reducing pain and stiffness, and enhancing mobility.

So simply put, just like other HA brands, Monovisc injections are designed to closely mimic the viscous and elastic properties of the joint’s natural fluid.

This study (Monovisc injections, 1) compared the rheological properties (how the hyaluronic acid flows and changes shape under pressure) of various intra-articular HA products, including Monovisc.

And it discovered that products with higher molecular weight HA (like Monovisc), seem to be more durable and longer-lasting.

Which of course is important, as one of the primary goals of viscosupplementation is to provide long-lasting pain relief.

Unlike corticosteroids which usually provide short-term relief due to their powerful anti-inflammatory properties.

So is Monovisc a steroid?

No, Monovisc isn’t a corticosteroid or any steroid for that matter.

It’s a form of synthetic, cross-linked Hyaluronic Acid designed to supplement the natural Hyaluronic Acid of our joints.

There are other similar brands which offer hyaluronic acid injections. And some provide different versions of HA which may be more befitting for your particular condition.

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

Monovisc Injections Contain Cross-Linked HA

Besides being of high molecular weight, the Hyaluronic acid inside a Monovisc injection is also lightly ‘cross-linked’ (2).

Cross-linking is a chemical process whereby polymer chains are linked together through covalent bonds.

This effectively alters the physical and chemical properties of the original polymer.

And in the context of hyaluronic acid (HA), cross-linking creates bonds between the individual HA molecules to form a more complex, branched network.

Resulting in increased molecular weight and changes in the Hyaluronic Acid’s rheological properties. This affects its viscosity, elasticity, and degradation rate.

Cross-linked HA is more resistant to the enzymatic breakdown of the body, prolonging its presence and enhancing its durability within the joint space (3).

So in simple terms:

You can envision the cross-linking of Hyaluronic Acid similar to weaving together individual threads to create a stronger, more resilient fabric.

Hyaluronic acid (HA) naturally exists in the body as individual polymer chains (similar to threads). And by cross-linking, we chemically bind these chains together.

This results in a complex, interconnected network, much like a tightly woven piece of fabric. Making it more resistant to being broken down and extending its functional life within the joint space.

The Problem With Cross-Linked HA

Even though cross-linked Hyaluronic Acid is more durable, and in theory, should provide prolonged joint lubrication, it comes with downsides.

Cross-linked HA isn’t naturally found in the human body. The HA we have in our joints, skin, connective tissue and even the vitreous of the eye is typically linear without complex, network-like arrangements.

Therefore, at a molecular level, cross-linked HA isn’t representative of the structure or characteristics of natural HA.

And only certain soluble parts of cross-linked HA have been shown to interact with the CD44 receptors (4).

The CD44 receptor itself is like a docking station found on the surface of many cells in the body, including our joints.

It plays a crucial role in guiding cellular movements and tissue repair processes.

So although cross-linked Hyaluronic Acid is more durable, it’s not as bio-compatible as linear, non-cross-linked HA.

The more bio-compatible a substance is (in our case HA), the better it works with the body’s joints and surrounding tissues without causing harm or unwanted reactions.

For this reason, you would preferably want a moderate to high molecular weight Hyaluronic Acid which is also very bio-compatible.

Monovisc For Knee Pain Relief

Monovisc injections can indeed help with knee pain caused by osteoarthritis (OA).

As we discussed in the sections above, Monovisc is made from high-molecular-weight, cross-linked Hyaluronic Acid treatment.

Exogenous medium and high molecular weight (mw) HA is particularly useful for larger joints like the knee. Since the knee is a weight-bearing joint, the high molecular weight HA in Monovisc is more capable of withstanding these compressive forces. Therefore, provide longer protection and pain relief.

However, a study (5) comparing Ostenil PLUS (medium mw, non-cross-linked HA) versus MONOVISC® (higher mw, cross-linked HA) showed no significant difference between the two products, except for the WOMAC stiffness score.

“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 denote worse conditions.“

But most importantly, with Ostenil Plus, there was a notable WOMAC stiffness score improvement at month 1, which also persisted at months 3 and 6.

Whereas with Monovisc, there was only a notable WOMAC stiffness score improvement at month 1 but it did not persist at months 3 and 6.

Therefore, inferring from this preliminary data, Ostenil Plus seems to offer more long-lasting results.

But this study has a few noteworthy limitations.

Firstly, patients were allowed to use non-steroidal anti-inflammatory drugs (NSAIDs) and other analgesics, such as ibuprofen etc.

Also, as a part of the study design, patients were instructed to use diclofenac potassium, another NSAID.

And finally, there was no placebo control group.

How Long Does Monovisc Take To Work?

Monovisc usually begins working within a few days to a week after the initial injection. The maximum benefits can be observed within a month, although this varies between individuals.

Is Monovisc a One Time Treatment

Yes, Monovisc is designed as a single-injection treatment, providing relief for up to six months.

How Many Monovisc Injections Can You Have?

Patients can get repeat Monovisc injections once the effects of the previous injection have diminished. This typically occurs after six months.

Monovisc Injections – Price

In the UK, Monovisc injection prices can range from £300 – £420+ 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 Monovisc injections, which ensures accuracy in delivering the hyaluronic acid directly into the affected joint space.

And are Monovisc Injections available on the NHS?

Unfortunately, rarely.

As per the NHS commissioning decision:

“Hyaluronic Acid injections (or viscosupplementation) 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 Monovisc via the NHS, great.

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

Monovisc Injections – Patient Reviews

What do people who’ve had Monovisc say?

Let’s break down the patient data into two groups – empirical (scientific) and anecdotal (word of mouth).

Empirical:

In section 4 of our article, we already examined this study (5), comparing Ostenil Plus vs Monovisc.

With Ostenil Plus, patients had joint stiffness improvements at months 1, 3 and 6.

With Monvisc, patients had joint stiffness improvements only up until month 1. It didn’t persist in months 3 and 6.

Also, in the study, patients were randomly assigned to either the Ostenil Plus or Monovisc group.

And it just so happened that the patients in the Ostenil Plus group had more severe forms of osteoarthritis, on average.

Therefore, Ostenil outperformed Monovisc in terms of efficacy while having to deal with more severe forms of osteoarthritis.

Meaning, if the patients with different levels of osteoarthritis severity were distributed equally, Ostenil Plus could’ve outperformed Monovisc even further.

However, as we emphasised above, this study has limitations. It allowed for the use of NSAIDS and had no placebo-control group.

When conducting scientific inquiry, we want the least amount of confounding variables.

So knowing that NSAIDs were allowed, all inferences from this study must be interpreted with caution.

Anecdotal:

As for anecdotal (word of mouth) patient reviews, there are quite a few online.

According to (Patient Reviews) the opinions are mixed, some patients have had tremendous pain relief from Monovisc injections, while others haven’t had much improvement.

This type of mixed outcomes can be seen across all Hyaluronic Acid injection brands.

Individual responses can vary significantly due to differences in joint morphology, genetic predispositions, the stage and severity of osteoarthritis, as well as overlapping effects of previous treatments.

So our consensus is that Monovisc injections are beneficial or net-neutral for most people.

However, Monovisc must be administered by an experienced injection specialist with ultrasound guidance.

Otherwise, complications may occur or Monovisc might not work as intended.

For these reasons, you must ensure to only work with qualified professionals who have sufficient experience with intra-articular (joint) injections.

What to Expect During The Procedure?

The Monovisc injection procedure is quite straightforward and minimally invasive.

In most cases, the doctor or injection specialist will first apply a local anaesthetic to completely numb the area.

Then they will use ultrasound to accurately guide and inject Monovisc 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.

After the injection, some may notice immediate relief, while for others, the reduction in pain and improvement in joint function may develop over the following weeks.

What Are The Side Effects of Monovisc?

Monovisc was introduced to the market in 2007 by Anika Therapeutics, Inc.

And it has accumulated plenty of empirical and anecdotal data since then.

Thousands of people have had Monovisc injected in joints commonly affected by Osteoarthritis.

And most haven’t had any serious adverse side effects.

However, 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 hyaluronic acid injection, not just Monovisc. That’s because all HA injections have the same mechanism of action and similar excipients. Therefore similar side effects can be expected. But these adverse reactions depend primarily on the skillfulness and care of the injection specialist or doctor.

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.

Therefore Monovisc is considered generally very safe.

Also, it’s important to note, that just like many other HA injection brands, Monovisc 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 Monovisc or any other hyaluronic acid injection, consider the following:

• Ultrasound Guidance: Ensure your doctor is using ultrasound to guide the injection. As this study demonstrated (6) 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.
• Combined Therapy: Theoretically, combining Hyaluronic Acid with a Corticosteroid (such as Cortisone) may reduce the risk of an acute inflammatory reaction or pseudosepsis. Corticosteroids block pro-inflammatory mediators, suppress the production of cytokines, and prevent factor NF-κB from activating, all of which decrease inflammatory gene expression (7). Therefore, in theory, corticosteroids can reduce the risk of acute inflammation or pseudosepsis. And even augment the positive effects of HA. However, corticosteroids themselves can have side effects. This includes potentially impacting blood sugar levels and the tissues around the injection site. So you and your doctor should carefully consider the pros and cons of combined HA + Corticosteroid therapy.
• Treatment Quality: Ensure the Hyaluronic Acid brand your doctor uses is of high quality and sourced from reputable manufacturers, such as Monovisc. 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 Monovisc is:

• Hyaluronic Acid (fermentation via a proprietary bacteria strain)
• Sodium Chloride
• Potassium Chloride
• Sodium Phosphate, Dibasic
• Potassium Phosphate, Monobasic
• USP water for injection

The Hyaluronic Acid is the active ingredient, it replenishes the joint’s synovial fluid.

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 Monovisc?

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

And we have reviewed the top ones:

• Ostenil
• Durolane
• Cingal
• 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 Monovisc because that depends on multiple factors.

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 as 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 Monovisc an Effective Treatment?

Monovisc injections are similar to the other Hyaluronic Acid injection brands we’ve discussed on our website in depth.

In terms of composition, Monovisc is a single injection, high-molecular-weight, cross-linked, bacteria-derived Hyaluronic Acid treatment.

In terms of pharmacodynamics (its effect), Monovisc supplements the joint’s synovial fluid. It lubricates and provides ‘cushioning’, thereby reducing pain and stiffness and enhancing mobility.

Based on the empirical evidence and patient data shown in this article, Monovisc injections have demonstrated sufficient clinical efficacy.

However, one of the studies we reviewed found Ostenil Plus to outperform Monovisc.

Also, the Hyaluronic Acid in Monovisc is cross-linked which has lower bio-compatibility.

So the effectiveness of Monovisc can vary among individuals and 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.

Overall, Monovisc is a top contender. And if it’s the only HA injection treatment you have access to, it’s worthy of consideration.