Download Indications and Contraindications, Effects and SideEffects

Indications and Contraindications, Effects and SideEffects
of ultrasound-guided steroid injections
Poster No.:
C-1582
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
E. A. Dick, A. Kindelerer, I. Anwar, A. K. Lim; London/UK
Keywords:
Drugs / Reactions, Biological effects, Treatment effects,
Complications, Ultrasound, Musculoskeletal soft tissue,
Musculoskeletal joint
DOI:
10.1594/ecr2015/C-1582
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Learning objectives
To understand the indications for steroid injections of the joints and soft tissues.
To be aware of interactions of other medications and steroids.
To understand the potential adverse effects of steroid injections, and which preparations
have greater or lesser risk of these.
Background
Radiologists are increasingly asked to perform Ultrasound guided injections of steroids
into or around the joints or tendons of patients to provide symptomatic relief from
arthropathy, bursitis and tendonitis.
Injectable corticosteroids have been used to treat arthritic joints for over 50 years (1).
However there are few controlled trials and much of the evidence on safety and efficacy
of steroids is anecdotal.
All steroids potentially interact with other medications. Before steroid administration
a drug history should be taken and the patient counselled taking into account the
information presented in this poster:
Interactions with other medication
1. Blood thinning agents - including Aspirin & Warfarin.
The National Institute for Clinical Excellence (NICE) recommends that caution is used if
the patient is taking anti-coagulant medication (2).
The increased risk of bleeding and bruising should be explained and appropriate
measures (increased compression time) taken if required.
2. Diabetic medication.
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Blood sugar levels will rise slightly after steroid injections of soft tissues for 1 to 21 days
(3, 4). However in a study of hand and wrist extraarticular injections, these elevated levels
are generally not clinically significant (4). Intraarticular injections have little effect on blood
sugar.
3. Antiretroviral treatment with Ritanovir - a protease inhibitor.
Steroid injections are contraindicated in patients on Ritanovir because of the
recently recognised risk of adrenal insufficiency:
In 2009 two HIV infected patients being treated as part of their highly active anti-retroviral
treatment (HAART) developed Cushings Syndrome and adrenal suppression after intraarticular triamcinolone acetate administration. The mechanism is due to increased
systemic concentrations of triamcinolone (over 10 x normal levels) due to inhibition
of the cytochrome p450 3A4 metabolism. The symptoms of Cushings developed two
weeks after the injection. In both patients, the secondary adrenal insufficiency settled
with conservative management. (5).
After this initial case report a retrospective study of 171 HIV infected patients who
received one or more corticosteroid injections was conducted. Nine patients developed
biochemical adrenal insufficiency of whom five had Cushings Syndrome. All patients who
developed adrenal insufficiency were on Protease Inhibitors. The risk was greater with
more than one injection within a six month period (6).
The most recent advice is that 11% of patients on Protease Inhibitors who need
steroid injections develop adrenal insufficiency and therefore steroid injections
should only be used with great caution and close monitoring (6).
Who, where, why to inject?
Who:
1. Seropositive and seronegative inflammatory arthritides 2. Crystal arthritides (gout and
pseudogout) (1). 3. Osteoarthritis - intraarticular injections (2, 7).
Where:
1 Intra or periarticular.
2 Soft tissue - bursa, tendon sheaths, around nerves (such as the carpal tunnel) or into
or around tendon insertions (eg common extensor epicondyltis at the elbow) (3).
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Why:
The therapeutic aim may be complete and permanent cure of pain, or providing a pain
free window , which may be used for rehabilitation, with the expectation of a repeated
injection for future pain relief (3). Improved muscle strength and range of movement may
also be achieved (1).
How Often to Inject?
NICE recommends that no joint should be injected more than three times a year in
Osteoarthritis. The American College of Rheumatology advises against repeated and
numerous injections in the same joint. (8)
Absolute Contraindications:
These include injection into a prosthetic joint, injection at a site of possible infection or
through a site of possible infection. Injection of a fracture is contra-indicated (2)
Which anatomical site is there good evidence for efficacy of corticosteroid
injection?
De Quervains tenosynovitis: Considered the preferred initial treatment (9). 90% of
patients responded to a single intra-tendon sheath steroid injection (10).
Trigger finger: Two randomized controlled studies have shown single corticosteroid
injections of methylprednisolone or betamethasone was successful in 60% (compared
with 20% for local anaesthetic alone) (11).
Carpal Tunnel Syndrome: Good evidence that it is effective (1)
Lateral epicondylitis: Good evidence for short term pain relief (12)
Subacromial bursitis: Good evidence for short term pain relief. A study of patients from
the Hospital for Joint Diseases, New York, compared patients who received triamcinolone
nad lidocaine with those who received lidocaine alone into the subacromial bursa. At a
mean of 30 weeks post injection the steroid group showed benefit in reducing pain and
increasing range of movement (13).
Greater trochanteric pain syndrome: Effective treatment in the short term (one week) in
77% (1, 14)
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Knee: Intraarticular corticosteroid can reduce pain and increase range of movement in
patients with osteoarthritis for up to3-4 weeks. (7).
Which steroids should be used?
There are a variety of injectable steroids available, with variable solubility, length of effect
and adverse effects.
Preparations:
Depot formulation remain at the injected site for a long time and display local effects.
Commonly used depot formulations include: methylprednisolone acetate, triamcinolone
acetonide, triamcinolone hexacetonide and hydrocortisone acetate.
Solubility:
Solubility is important.
Triamcinolone hexacetonide and triamcinolone acetonide (Kenalog) are the least soluble.
Methylpredinosolone acetate (depomedrone) and hydrocortisone are more soluble (3).
Insoluble steroids maintain synovial levels for longer, have less systemic effects but a
higher incident of cutaneous side effects (3).
Some data suggests low solubility correlates with a more sustained effect, but others
suggest the opposite (1, 15).
Low solubility compounds are well suited for intra-articular injections but may not be so
well suited to soft tissue injections.
A Survey of American Rheumatologists found that choice of corticosteroid varied with
geographical location of training of the Rheumatologist. Only triamcinolone hexacetonide
was chosen primarily for efficacy (16).
NICE guidelines are that in Osteoarthritis small joints should be injected with
methylprednisolone or hydrocortisone and large joints should be injected with
methylprednisolone or triamcinolone acetonide (2).
Local Anaesthetic:
Additional local anaesthetic helps to differentiate local from referred pain.
Page 5 of 12
If mixed with local anaesthetic, careful inspection of the mixture to exclude flocculation
is required prior to injection (1).
Mechanism of Action:
Injectable depot corticosteroids have a
Local Action:
-reduce inflammation in synovial tissues
-reduce oedema
-reduce number of lymphocytes, macrophages and mast cells
-reduce number of inflammatory cells within a joint in the long term (1)
Systemic Effects: (Dose related)
-lower Erythrocyte Sedimentation Rate
-lower C Reactive Protein
-may cause less inflammation in non-injected joints (1)
Effect on Articular Cartilage:
There is debate about whether corticosteroids hasten chondrocyte death in osteoarthritis
(17). A study by Raynaud et al is reassuring: 68 patients with knee osteoarthritis received
injections of triamcinolone acetonide 40mg or saline every three months for two years.
While there was no effect on deterioration of osteoarthritis as judged by joint space loss,
those who received steroid did have improvements in the range of movement (18).
In Osteoarthritis, degeneration of cartilage is accompanied by decreasing
responsiveness of chondrocytes to circulating glucocorticoids, resulting in increased
cytokine production. This is theorised to cause more cartilage degradation, therefore
intra-articular steroids may arrest this process (18).
However, more recently investigations on the effects local anaesthetic agents alone
and in combination with corticosteroids has shown that local anaesthetic agents can be
chondrotoxic alone or in combination with corticosteroid (17, 19)
Page 6 of 12
Ultrasound guided versus Clinically Guided Injections:
There is surprisingly little evidence on this. However Naredo et al's landmark paper (20)
showed ultrasound guided subacromial injections were significantly better at reducing
pain and increasing shoulder function.
Aspiration prior to Injection:
Successful aspiration of fluid is associated with increased chance of successful response
ot steroid and lower likelihood of return of symptoms (21). This may be because the joint
is less painful and stiff, or because the corticosteroid is not so diluted.
Care after injection:
There is contradictory evidence regarding the value of resting a joint after injection. NICE
recommends resting for 24 hours. Rheumatologists in the USA vary in their post-injection
instructions: 29% do not restrict weight-bearing but 8% restrict weight bearing for 1 week
or more (16). The effect of resting may not be apparent in the short term (eg up to 3
weeks post injection) but may be more recognisable towards the end of recovery (24
weeks) (22).
Findings and procedure details
What should be included in the consent process?
In addition to the usual risks of intervention (infection, discomfort, haematoma),
radiologists should explain the risks of steroid:
1 'flare' - worsening symptoms for a few days. This is an acute inflammatory reaction/
chemical synovitis due to the microcrystalline suspension. It is thought to occur in
0.1-10% of patients (2, 8)
2 depigmentation, fat atrophy and striae - Cutaneous atrophy has been shown to
occur with all corticosteroid preparations (23) but is worse with non-soluble steroid eg
triamcinolone preparations and rarer after methylprednisolone or hydrocortisone acetate
(24). This also occurs with intra-articular injections when peri-articular leakage of steroid
occurs. The risk is greatest with large or repeated doses of long-acting potent steroid (2).
Page 7 of 12
Skin atrophy and depigmentation my be reversible after a number of years but striae are
usually permanent (24)
3. tendon rupture - theoretically worse with non-soluble steroids. This is rare but has
been reported both with intratendinous injection and peritendinous injections (25).
4. Flushing. Occurs in up to 15% of patients, more commonly female, onset within a few
hours, effect lasts 3-4 days. (25, 1)
Images for this section:
Fig. 2: Ultrasound guided needle advancement into 4th MTP joint
Page 8 of 12
Fig. 3: (same patient as Fig 2) Needle tip positioned in 4th MTP joint for steroid injection
Fig. 1: Ultrasound guided injection of 1st CMC joint
Page 9 of 12
Conclusion
Steroid injections can interact with other medication and have adverse effects, both of
which should be considered and discussed with the patient pre-procedure.
Personal information
References
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2
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2014
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evidence. Am Fam Physician 2008 78(8) 971-976.
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