Elsevier

Joint Bone Spine

Volume 74, Issue 5, October 2007, Pages 472-476
Joint Bone Spine

Original article
Systemic effects of epidural and intra-articular glucocorticoid injections in diabetic and non-diabetic patients

https://doi.org/10.1016/j.jbspin.2006.10.009Get rights and content

Abstract

Introduction

Whereas the systemic effects of glucocorticoid therapy have been extensively reported, little is known about those of local glucocorticoid injections. The objective of this study was to look for systemic effects of local glucocorticoid injections at two sites in diabetic and non-diabetic patients.

Methods

We studied 29 patients (18 women and 11 men with an age range of 18–86 years). The injection site was the epidural space in 18 patients (4 with and 14 without diabetes) with disk-related sciatica and the shoulder in 11 patients (8 with and 3 without diabetes) with frozen shoulder. Each patient was given three injections of 1.5 ml cortivazol (5.625 mg of cortivazol or about 85 mg prednisone-equivalent per injection and about 250 mg prednisone-equivalent in all), at 3-day intervals. Of the 12 patients with diabetes, 2 were on insulin therapy. At baseline and at the post-treatment visits 1, 7, and 21 days after the third injection, the following tests were done: plasma cortisol and ACTH at 8 am, urinary free cortisol excretion in 24 hours, fasting and postprandial blood glucose, serum cholesterol and triglycerides, and serum sodium and potassium. Blood pressure was measured at each visit.

Results

Mean systolic blood pressure increased significantly between baseline (123 ± 10 mmHg) and the first two post-treatment visits (day 1, 127 ± 9 mmHg; and day 7, 128 ± 10 mmHg) but returned to baseline values by the third post-treatment visit (day 21). Mean postprandial blood glucose was significantly higher at the day 1 post-treatment visit (10.1 ± 5.4 mmol/l) than at baseline (7.5 ± 2.9 mmol/l). At the day 7 post-treatment visit, blood glucose remained significantly elevated compared to baseline in the 12 diabetic patients (13.9 ± 4.8 mmol/l versus 9.4 ± 3.3 mmol/l at baseline). In both the overall population and the various subgroups, plasma cortisol and ACTH and urinary free cortisol were markedly reduced at the day 1 and day 7 post-treatment visits, compared to baseline. At the day 21 visit, these variables were diminished in the group given epidural injections, whereas plasma cortisol and ACTH were normal in the group treated intra-articularly. No significant variations were noted for fasting blood glucose or for serum levels of cholesterol, triglycerides, sodium, and potassium.

Conclusion

The administration of three local cortivazol injections was followed by suppression of the corticotropic axis that persisted beyond 21 days after epidural injection and recovered more rapidly after intra-articular injection. Systolic blood pressure increased transiently. Elevations in postprandial glucose levels lasted longer in diabetic than 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

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