Platelet Rich Plasma (PRP) has been around for a long time, but patients are often confused by it. In part the confusion arises from how it is marketed, which sometimes includes it being described as “stem cells”, which it is not. However, at times it can be as a therapy with stem cells or other biologics, which also adds to the complexity.
To help clarify where things stand including on the clinical science, I’m going to do a series of new posts on platelet rich plasma.
We start the series today with an interview with an expert on it, Dr. Drew Lansdown of UCSF. I also highly recommend a YouTube video of Lansdown giving a talk on platelet rich plasma, which I’ve pasted at the bottom of the post.
Note that I have a new series of polling on stem cell and related treatment coasts including for PRP so please participate if you’ve had PRP therapy.
Here’s the interview with Dr. Lansdown.
What are the main types of platelet rich plasma and what makes them different? Which type do you use and why?
DL: There are a few different ways that PRP can be classified. One way is based on the presence of leukocytes, or white blood cells. This grouping divides PRP into leukocyte-rich and leukocyte-poor PRP. Removing the leukocytes takes an extra step in preparation. The presence of leukocytes may produce more of an inflammatory response in the early period after the injection. The other way to classify PRP is based on the presence or absence of fibrin. Fibrin leads to activation of PRP, which produces a more gel-like consistency. This form may be more appropriate for direct applications in surgical treatment. Leukocyte-poor PRP is generally favored for joint injections, while leukocyte-rich PRP may be used in tennis elbow (lateral epicondylitis).
What do you think is the type of medical condition that has the most compelling data in favor of PRP use over more traditional approaches/standard of care?
DL: I think we still need more data to really establish if PRP should be used over traditional approaches or could be considered standard of care, and at this point, I would favor considering PRP at times if traditional treatment options are not proving sufficient. The conditions that currently have the best evidence to support the use of PRP are early mild-to-moderate knee osteoarthritis and lateral epicondylitis (tennis elbow). There are multiple randomized controlled trials demonstrating effectiveness for both of these conditions, though there are trials for both that also show no or a more limited effect of PRP. I think this highlights the need for further research to define which patients will respond and where these injections may play a role for treatment.
Are there conditions for which you wouldn’t advise PRP use at this time based on the data?
DL: I do not think we have enough evidence at this time to support the use of PRP in the shoulder, for either rotator cuff injuries or shoulder arthritis. Other tendon conditions, like Achilles tendinitis, also do not have enough data to routinely support their use.
How long does the benefit of PRP last?
DL: It seems from the studies that we have that results may last for about 1 year. This expected duration of benefit though does need to be clarified.
I saw your Bendich, et al. paper on PRP cost for knee OA. You concluded, “For patients with symptomatic knee osteoarthritis, PRP is cost-effective, from the payer perspective, at a total price (inclusive of clinic visits, the procedure, and the injectable) of less than $1,192.08 over a 12-month period, relative to HA and saline solution.” You also wrote, “cost would have to be less than $3,703.03” for a 6-month period. How do these numbers compare to what patients are actually paying and how often are they getting PRP?
DL: The difference in the 6 month and 12 month costs are a potentially confusing part about this paper. In the published trials that we used for this study, saline actually had more of an improvement than hyaluronic acid at 6 months after injection, while the reverse was true at 12 months. This happened because we included different trials that reported results at different time points. For this reason, the PRP cost at 6 months (relative to the cost of saline, which is inexpensive) was actually higher than the 12 month cost (relative to HA, which is more expensive).
Patients are often paying more than this amount, which is important to note includes the cost of the clinic visit, and injection procedure. Patients may be charged up to $2000 or even more for an injection. Some patients will receive recommendations for multiple injections as well, which further drives up the cost to the patient.
In a nutshell, are most patients having a cost-effective experience?
DL: I think that many patients are not having a cost-effective experience with PRP. Since these injections are rarely covered by health insurance and are paid for directly by the patients, there is no real standardization for the amount charged for the injections as there is for other medications/treatments. That was part of the motivation for this study, to try and provide some relative cost based on other treatments that are commonly used for knee osteoarthritis.
What’s your view of direct-to-consumer clinics selling PRP? Does it vary by the specific clinic/brand in terms of whether it’s wise for patients to go that route?
DL: I think that some of the direct advertising can be misleading to patients as to the actual potential effects of PRP. Some of the advertisements suggest that PRP can be a cure-all and may convince patients to spend large amounts of money on a treatment that may not be beneficial for them. I think it is important for patients to understand that, while there is much excitement about PRP, there is still much that we do not know.
Note from The Niche that this post is not meant as medical advice. Talk to your doctor before making any medical decisions, including about platelet rich plasma.
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Again a good review but two main issues:
1. It is now 5 years old. There are now multiple, additional MUCH better studies since then including a couple of Meta-analysis in the Journal Arthroscopy in 2018.That said there remains issues with what everyone describes as “PRP” in both clinical practice and unfortunately published articles which fails to describe the components of what is given to patients or research subjects. This is analogous to not describing how many mgs and dose schedule in treating a patient with antibiotics for an infection. We know that is not acceptable and likely to cause confusion on whether it “works” or not. This deficiency is found even in studies that looks so good on the surface: double-blind, randomized controlled studies. I have had to send in a letter to the journal editors.(DOI: 10.1177/0363546519879424) EVEN with these deficiencies, the literature clearly supports PRP for mild to moderate knee OA and (probably hip OA as well) and “tennis elbow” and greater trochanteric pain (aka “bursitis). There are likely benefits in other MSK conditions as well that need better study including information from national registry databases which I feel will be invaluable to patients, clinicians and regulatory and insurance groups on what “works” or does not work.
2. The authors used “pooled data” to make their conclusions. This would likely lead over simplified results. The data needs to be specific for EACH conditioned studied and even that needs further stratification. For example: mid-substance vs insertional Achilles tendinopathy is well known to respond differently to different treatments.
Appreciate being able to clarify SOME of these issues. There is great potential in these various biologics that merits further CLINICAL investigation and then proper application in patients.
I’ve had single spin PRP and double spin PRP. The double spin I believe is used to concentrate that portion of the plasma containing growth factors which may bring about a more robust healing process. (Whatever!) At times following the injections, my knees are fairly sore for a couple of days. Other times, there is no soreness. As an arthritis patient, it makes no difference to me as far as functionality and pain in my knees are concerned.
PRP is expensive because insurance does not financially cover this regenerative procedure. Furthermore medical insurance probably does not have any intention of ever doing so because of economics and scientific politics than for reasons of efficacy and patient safety (in my opinion).
There is a Dr. Kevin Stone MD in the San Francisco bay area who runs The Stone Clinic. My understanding is that he no longer utilizes the Standard of Care cortisone injections…..and for good reason. Quite the opposite of having a regenerative effect on joints, cortisone and other similar injections have instead a degenerative effect. Yet steroid injections remain the Standard of Care for joint related problems well before PRP is ever considered. Might this cortisone Standard of Care diminish the potential efficacy once a physician or surgeon finally decides to employ more regenerative techniques like PRP and adult stem cells?
It seems irrelevant just because there is much the scientific/medical establishment does not know about PRP that their unfamiliarity should stand in the way of regenerative medicine being utilized clinically TODAY. The safety profile on regenerative techniques like PRP, given the length of time that it has been utilized (since the 20th century) has yet to demonstrate the destructive tendencies comparable to cortisone.
Appreciate your perspective as a patient Doug. You are correct in the things you note regarding cortisone and the negative effects of it ; yet it remains “standard of care”. You are also correct regarding the safety of PRP and other “Regenerative” treatments. I am completing a review paper of the history and the medical literature on cortisone which is filled MANY negative effects and LIMITED effectiveness (short term). I am also putting together a MASSIVE paper on the Safety and Efficacy of Regenerative treatments for Orthopedic conditions with multiple authors. Be well and Stay tuned !
Thanks for your input Gerard. Nice reply. Best.
Doug
Why people get so inconsistent results with PRP ?
It’s in part due to so many different methods to make PRP. One place’s PRP can be totally different than another. Also, each patient’s blood and cells are different to start with.
What do you suggest as a QC/QA to make it consistent: How do you control QC, what do you use to check if you have platelets in your prep in sufficient numbers and you do not lose platelets during the prep stages
There are easy to use cell counters that each clinic that offers these treatments can buy. At our practice we count every blood product we deliver MEASURING the increase in number of platelets, DECREASE/REMOVAL of RBCs and WBCs to produce a high-quality product. We also perform data outcomes on all willing patients !
“PRP” is a term that is loosely used with a WIDE variation of how many platelets, presence of red cell, white cells; how it is delivered (i.e. US guidance) and many other factors that unfortunately many practitioners are not taking into account when providing PRP treatments.
With 100s of places selling “PRP” and so many different methods, how can any patient know what they are getting? Few practitioners selling PRP have published on their own method of preparation and deployment for specific conditions.
Patients should ask if their provider has a cell counter (which they CAN get) and ask for print out of THEIR OWN PRP product after processing. This would include the pre/post platelet count (which can give you the concentration of platelets); WBCs and RBCs that are delivered along with the volume that they get injected. The literature is now much more clear on what is a more optimal product.
I wonder if you could comment on Dr. Spiel’s use of exosomes also there in NJ for many conditions and apparently some involvement in facilitating a COVID-19 exosome infusion? It seems like standards for characterization and quantification of exosomes is far behind PRP, stem cells, etc, not to mention FDA compliance issues.
The use of Exosomes is of great concern to me and other thought-leaders in Regenerative medicine. The current evidence for using these products is almost nonexistent, especially in my primary area of interest: orthopedic conditions. It is also being used for neurologic conditions such as MS, Parkisons and spinal cord injury taking advantage of a very desperate and vulnerable group of patients. Now recently, there has been a marketing of these products taking advantage of the current COVID-19 situation, AGAIN without any level of prior clinical rationale and used without appropriate FDA compliance i.e. clinical trial with an IND. As you know, the FDA has now sent letters to both Dr. Spiel and the CEO of one company marketing these products.
Patients need to be aware that Exosomes are made from other humans and contain mRNA material from them which can interact with a patient’s own genetics. THAT seems very scary to me and AGAIN without ANY clinical trial to support it’s safety and efficacy for clinical conditions.
Nice overview but pretty basic. Many other thought-leaders who provide a more in-depth review of PRP. This was done at the 2020 Interventional Orthobiologics (IOF) meeting by Dr. Jeremy Magalon of France. In addition, IOF will be completing a massive White paper on the Safety and Efficacy of OrthoBiologics for orthopedic conditions. “PRP” is NONSPECIFIC term and used loosely in medical literature and thus the conflicting results. The biggest problem is the lack of real world evidence (RWE) which is being addressed by a novel registry database called DataBiologics.
What about this Cochrane review? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4457756/