Corticosteroid local injection

When higher concentrations of drugs, particularly corticosteroids and antibiotics, are required in the eye than can be delivered by topical administration, local injections into the periocular tissues can be considered. Periocnlar drug delivery includes subconjunctival, snb-Tenon s, retrobulbar, and peribulbar administration. 

There is no general case for using intra-articular corticosteroid in osteoarthritis but local injection of triamcinolone can provide relief for a single periarticular tender spot or for a knee joint that is acutely inflamed. 

Audicort Aureocort Aristocort Kenalog Ledercort ) is a corticosteroid, a glucocorticoid with ANTIINFLAMMATORY and ANTIALLERGIC properties. It is most commonly used in the form of the acetonide, to suppress the symptoms of inflammation, especially when it is caused by allergic disorders. It is sometimes used systemically to relieve conditions such as hay fever and asthma. It is commonly given by local injection to treat skin inflammation due to rheumatoid arthritis and hursitis. There are a number of topical preparations to treat severe, non-infective skin inflammation, such as eczema, or for treating inflammation in the mouth and ears. 

By intraarticular injection medicines, e.g. containing corticosteroids, local anaesthetics as active substances, are administered into the joint. 

Since corticosteroids reduce the immunological defences of the body to most types of infection, their use in the eye should be monitored carefully. The specific type of ocular disease and its response to steroid therapy may determine whether to use topical, systemic and/or local injections. Systemic side effects do not generally occur with limited topical administration. 

Common mild local adverse reactions include induration and swelling at the injection site. More severe reactions (generalized urticaria, broncho-spasm, laryngospasm, vascular collapse, and death from anaphylaxis) occur rarely. Severe reactions are treated with epinephrine, antihistamines, and systemic corticosteroids. 

The limited penetration of topical corticosteroids can be overcome in certain clinical circumstances by the intralesional injection of relatively insoluble corticosteroids, eg, triamcinolone acetonide, triamcinolone diacetate, triamcinolone hexacetonide, and betamethasone acetate-phosphate. When these agents are injected into the lesion, measurable amounts remain in place and are gradually released for 3-4 weeks. This form of therapy is often effective for the lesions listed in Table 61-2 that are generally unresponsive to topical corticosteroids. The dosage of the triamcinolone salts should be limited to 1 mg per treatment site, ie, 0.1 mL of 10 mg/mL suspension, to decrease the incidence of local atrophy (see below). 

Sandberg DI, Lavyne MH. Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections case report. Neurosurgery 1999 45(l) 162-5. 

Rimbaud P, Meynadier J, Guilhou JJ, Meynadier J. Complications dermatologiques locales secondaires aux injections cortisonees. [Local dermatological complications secondary to corticosteroid injections.] Nouv Presse Med 1974 3(ll) 665-8. 

Drugs are applied to the mucous membranes of the conjunctiva, nasopharynx, and vagina to achieve local effects. On the other hand, the antidiuretic hormone lypressin (Diapid) is given by nasal spray, but the intention is to produce systemic effects. For the treatment of meningeal leukemia, cytosine arabinoside is injected directly into the spinal subarachnoid space. In osteoarthritis, corticosteroids are given by intra-articular injection. 

There are many types of steroid hormones in the body, such as the sex/gonadal hormones testosterone and estrogen, thyroid hormones, growth hormones, and stress hormones, which serve various normal functions. One type of steroid— corticosteroids or glucocorticoids—is secreted by the adrenal glands (located just above the kidneys). These steroids, particularly synthetic versions of them, have powerful antiinflammatory actions that help to relieve pain. They are often given as an epidural injection to relieve neck or back pain that results from a compressed or pinched nerve. They can also be injected directly into a joint to relieve pain caused by inflammation in conditions such as tendonitis (inflammation of the tendons), carpal tunnel syndrome, tennis elbow, bursitis (inflammation of sac-like cavities in tendons or muscles that allow them to slide easily over bone), or other joint pain. Professional athletes, who routinely experience one or more of these conditions, are often given local steroid injections. Frequently, the steroid is combined with a local anesthetic such as lidocaine. 

The reaction may be either local or systemic. Symptoms vary from mild irritation to sudden death from anaphylactic shock. Treatment usually involves intramuscular injection of adrenaline (epinephrine), antihistamines and corticosteroids. 

Use repository corticosteroid preparations with great care. They are irrecoverable once injected and cause protracted local immunosuppression. They are potentially disastrous if comeal ulceration supervenes. 

Treatment is symptomatic and supportive. The wound should be cleaned with soap and water tetanus prophylaxis should be administered. Application of ice packs or the topical application of a corticosteroid, antihistamine, or local anesthetics may be useful in relieving symptoms. Severe pain has been treated with injection of a local anesthetic. Antibiotics are reserved for documented infections. 

Corticosteroids can be used in various ways. They are valuable in controlling symptoms before the onset of action of DMARDs. A burst of corticosteroids can be used in acute flares. Continuous low doses may be adjuncts when DMARDs do not provide adequate disease control. Corticosteroids may be injected into joints and soft tissues to control local inflammation. Steroids seldom should be used as monotherapy. There are data to suggest they have disease-modifying activity however, it is preferable to avoid chronic use when possible to avoid long-term complications. NSAlDs and DMARDs have steroid-sparing properties that permit reductions of steroid doses. 

As discussed previously, corticosteroids downregulate VEGF production in experimental models and possibly reduce breakdown of the blood retinal barrier (15,16). Similarly, corticosteroids have antiangiogenic properties possibly due to attenuation of the effects of VEGF (20,21). These properties of steroids are commonly used. Clinically, triamcinolone acetonide is used locally as a periocular injection to treat cystoid macular edema secondary to uveitis or as a result of intraocular surgery (22,23). In animal studies, intravitreal triamcinolone acetonide has been used to prevent proliferative vitreoretinopathy and retinal neovascularization (24—27). Intravitreal triamcinolone acetonide has been used clinically to treat proliferative vitreoretinopathy and choroidal neovascularization (28-31). 

In some cases where there is involvement of only a few joints, corticosteroids (usually triamcinolone or hydrocortisone) can be administered locally by intra-articular injection to relieve pain, increase mobility and reduce deformity. 

Another example would be the administration of local anaesthetics and anti-inflammatory corticosteroids by intra- and extra-articular injections by physiotherapists involved in the ongoing management of rheumatology patients. 

Intraarticular injections of insoluble corticosteroid depot suspensions directly into painful inflamed joints can give dramatic relief to arthritic patients that can last 3-4 weeks. This can be viewed as localized therapy. Microcrystalline suspensions of 6-methylpred-nisone acetate, betamethasone diproprionate, and dexamethasone 21-pivalate are among the effective agents. 

Ko H-J, Kim Y-R, Park K-S, Cho C-S, Kim H-Y. Clinical Images Kienbock disease resulting from local corticosteroid injections. Arthritis Rheum 2009 60(6) 1596. 

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