Original articleSystemic effects of epidural and intra-articular glucocorticoid injections in diabetic and non-diabetic patients
Introduction
Glucocorticoids administered into the joints, epidural space, or tendon sheaths exert potent anti-inflammatory effects that are widely used to treat many rheumatic diseases. The risk of local adverse events, primarily infection, has deflected attention away from potential systemic effects of local glucocorticoid injections. Nevertheless, such effects have been known for many years [1]. Although most rheumatologists believe that local glucocorticoid injections can affect the control of diabetes or, more rarely, hypertension, no scientific data are available on this issue. Studies done after intra-articular [2], [3], [4], [5], [6] or epidural [7], [8] glucocorticoid injections showed rapid drops in plasma cortisol levels due to suppression of the hypothalamic-pituitary-adrenal axis (HPAA), which resolved after a few days or weeks. A few cases of prolonged suppression have been reported [9], [10].
The objective of our study was to investigate potential systemic effects of glucocorticoid injections into the epidural space or shoulder in patients with or without diabetes.
Section snippets
Methods
We prospectively enrolled 29 inpatients (18 women and 11 men) with a mean age of 38 years. Each patient received three local injections of 1.5 ml of cortivazol (Altim®) at 3-day intervals. The injections were given in the epidural space in 18 patients with disk-related sciatica and intra-articularly in 11 patients with frozen shoulder. Of the 29 patients, 17 were not diabetic and 12 had type 2 diabetes, which was managed with hypoglycemic agents (n = 9), diet alone (n = 1), or insulin (n = 2). Diabetes
Results
In the overall population, plasma cortisol and ACTH and urinary free cortisol showed large decreases at V1 and V7, compared to baseline, and smaller decreases at V21. Systolic blood pressure was significantly elevated at V1 and V7 compared to baseline, but the increases were small (from 123 ± 10 mmHg at baseline to 127 ± 9 mmHg at V1 and 128 ± 10 mmHg at V7) and resolved by V21 (Table 1). Postprandial glucose levels showed significant increases, which were larger in the patients with than without
Discussion
Our objective was to investigate potential systemic effects of local cortivazol injections, comparing diabetic to non-diabetic patients and intra-articular to epidural injections. The regimen of three injections at 3-day intervals is widely used in hospitalized patients. Considerable variability exists in the biological properties of glucocorticoids. Cortivazol, which is available as a suspension, is characterized by a long half-life, fairly marked metabolic activity, and strong HPAA
References (30)
- et al.
Reduction of cortisol levels after single intra-articular and intramuscular steroid injection
Am J Med
(1995) Lumbar and caudal epidural corticosteroid injection
Mayo Clin Proc
(1996)- et al.
Tachon's syndrome (suracute back and/or thoracic pain following local injections of corticosteroids). A report of 318 French cases
Joint Bone Spine
(2005) - et al.
Systemic effects from hydrocortisone acetate administered intraarticularly to rheumatoid patients
Lab Clin Med
(1953) - et al.
Plasma steroid levels after intraarticular injection of prednisolone acetate in patients with rheumatoid arthritis
Ann Rheum Dis
(1980) - et al.
Cushing's syndrome with suppression of the hypothalamic-pituitary-adrenal axis after intra-articular steroid injections
Ann Rheum Dis
(1985) - et al.
Transient suppression of endogenous cortisol production after intraarticular steroid therapy for chronic arthritis in children
J Rheumatol
(1997) - et al.
Hypothalamic-pituitary-adrenal axis suppression after repeated intra-articular steroid injection
Ann Rheum Dis
(1986) - et al.
The effect of intrathecal dexamethasone injection on plasma cortisol level
Br J Rheumatol
(1991) - et al.
Effets systémiques des injections épidurales de dexaméthasone
Rev Rhum
(1995)
Secondary adrenal insufficiency after intrathecal steroid administration
J Neurosurg
Acute adrenal crisis in patient treated with intra-articular steroid therapy
J Rheumatol
Report of the expert committee on the diagnosis and classification of diabetes mellitus
Diabetes Care
Adrenal suppression due to intra-articular corticosteroid therapy
Lancet
Evaluation of the pituitary-adrenal axis function following single intraarticular injection of methylprednisolone
Arthritis Rheum
Cited by (93)
Comparative Effectiveness of Corticosteroid Dosages for Ultrasound-Guided Glenohumeral Joint Hydrodilatation in Adhesive Capsulitis: A Randomized Controlled Trial
2023, Archives of Physical Medicine and RehabilitationMusculoskeletal corticosteroid injections: Recommendations of the French Society for Rheumatology (SFR)
2023, Revue du Rhumatisme (Edition Francaise)Sacroiliac Joint Interventions
2022, Physical Medicine and Rehabilitation Clinics of North AmericaIs there an association between lumbosacral epidural lipomatosis and lumbosacral epidural steroid injections? A comprehensive narrative literature review
2022, North American Spine Society JournalSustained low-dose dexamethasone delivery via a PLGA microsphere-embedded agarose implant for enhanced osteochondral repair
2020, Acta BiomaterialiaCitation Excerpt :Repeated high-dose injections [8,42] have been associated with adverse effects on growth of articular and growth plate chondrocytes [20,26], synoviocytes [72], and osteoblasts [1]. These side effects, as well as risks of systemic absorption, typically limit patients to 2-4 injections per year [7,11,34,55,58,86]. Dexamethasone (DEX), a synthetic glucocorticoid, is a common media supplement for chondrogenic cultures.