Intra-articular corticosteroids

Use corticosteroid intra-articular therapy or pulse therapy for disease flares... 

Management of an acute attack of gout involves the use of high doses of nonsteroidal anti-inflammatory agents (NSAIDs). Colchicine is useful in patients with heart failure where the use of NSAIDs is contraindicated because of water retention. Allopurinol and other uricosuric agents are not indicated for acute attacks as they may aggravate the condition. The use of an intra-articular corticosteroid injection in gout is unlicensed. 

Short-term use of corticosteroids such as prednisone or predisolone is indicated for relapses and for intra-articular administration. Symptomatic improvement is rapidly obtained but any progression of the destruction of bone and cartilage is not influenced by corticosteroids. 

Intra-articular corticosteroids are often helpful to alleviate painful symptoms and, when successful, are preferable to increasing the dosage of systemic medication. 

Corticosteroids are sometimes used in the treatment of severe symptomatic gout, by intra-articular, systemic, or subcutaneous routes, depending on the degree of pain and inflammation. The most commonly used oral corticosteroid is prednisone. The recommended dose is 30-50 mg/d for 1-2 days, tapered over 7-10 days. Intra-articular injection of 10 mg (small joints), 30 mg (wrist, ankle, elbow), and 40 mg (knee) of triamcinolone acetonide can be given if the patient is unable to take oral medications. 

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. 

For parenteral administration in intensive therapy or in emergendes, the sodium phosphate ester may be given intravenously by injection or infusion, or intramuscularly by injection. Dexamethasone sodium phosphate is also used in the treatment of cerebral edema caused by malignancy. The sodium phosphate ester is given by intra-articular, intra-lesional or soft tissue injection. Dexamethasone acetate may be given by intramuscular injection in conditions where corticosteroid treatment is indicated, but a prompt response of short duration is not required. 

Intra-articular corticosteroids may be useful in some patients, particularly if there is an acute flare of the disease. The joint is injected with a steroid and this can reduce inflammation and joint effusion. The joint should not be injected more than once every three months... 

For any minor injuries sustained during athletic training NSAIDs and corticosteroids (topical, intra-articular) suppress symptoms and allow the training to proceed maximally. Their use is allowed subject to restrictions about route of administration, but strong opioids are disallowed. Similarly, the IOC Medical Code defines acceptable and unacceptable treatments for relief of cough, hay fever, diarrhoea, vomiting, pain and asthma. Doctors should remember that they may get their athlete patients into trouble with sports authorities by inadvertent prescribing of banned substances. ... 

Intra-articular injection of corticosteroid (triamcinolone, hydrocortisone, prednisolone or dex-amethasone) is very effective when one joint is more affected than others. Benefit from one injection may last many weeks. Aseptic precautions must be extreme, for any introduced infection may spread dramatically. Too frequent resort to corticosteroid injection may actually promote joint damage by removing the protective limitation conferred by pain such injections in a single joint would not normally exceed three per year. Other aspects of the treatment of inflammatory arthritis are important but are outside the scope of this book. 

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. 

Corticosteroids also may be delivered by injection. The intramuscular route is preferable in patients with compliance problems, since a depot effect is achieved. Depot forms of corticosteroids include triamcinolone acetonide, triamcinolone hexacetonide, and methylprednisolone acetate. This provides the patient with 2 to 8 weeks of symptomatic control. The depot effect provides a physiologic taper, avoiding withdrawal reaction associated with hypothalamic-pituitary axis suppression. It should be noted that the onset of effect via this route may be delayed by several days. Intravenous corticosteroids may be used to provide the patient with large amounts of drug during a steroid burst to control severe symptoms. Intra-articular injections of depot forms of corticosteroids can be useful in treating synovitis and pain when a small number of joints are affected. The onset and duration of symptomatic relief are similar to those of intramuscular injection. The intra-articular route often is preferred because it is associated with the fewest number of systemic adverse effects. If efficacious, intra-articular injections may be repeated every 3 months. No one joint should be injected more than two to three times per year because of the risk of accelerated joint destruction and atrophy of tendons. Soft tissues such as tendons and bursae also may be injected. This may help control the pain and inflammation associated... 

Other calcium-containing crystals Monosodium urate monohydrate Neuropathic disorders Intra-articular corticosteroid overuse Avascular necrosis Bone dysplasia... 

Individuals with contraindications to NSAIDs (e.g., active peptic ulcer disease, renal impairment, heart failure, or history of hypersensitivity) or individuals who cannot ingest medications orally may be treated with intravenous corticosteroids or intra-articular corticosteroids. 

Corticosteroids may be used to treat acute attacks of gouty arthritis, but they are reserved primarily for resistant cases or for patients with a contraindication to colchicine and NSAID therapy. Doses of 40 to 80 USP units of adrenocorticotropic hormone gel are given intramuscularly every 6 to 8 hours for 2 to 3 days, and then the doses are reduced in stepwise fashion and discontinued. Intra-articular administration of triamcinolone hexacetonide in a dose of 20 to 40 mg may be useful in treating acute gout limited to one or two joints. Prednisone may be administered orally in doses of 30 to 60 mg for 3 to 5 days in patients with multiple-joint involvement. Because rebound attacks may occur on steroid withdrawal, the dose should be tapered gradually by 5-mg decreases over 10 to 14 days and discontinued. 

Intra-articular injections are sometimes used to administer a drug directly into a joint, for example with a corticosteroid in the treatment of arthritis or a contrast agent for imaging. 

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. 

Cortisone acetate or hydrocortisone usually is the corticosteroid of choice for replacement therapy in patients with adrenocortical insufficiency, because these drugs have both glucocorticoid and mineralocorticoid properties. Following oral administration, cortisone acetate and hydrocortisone acetate are completely and rapidly deacetylated by first-pass metabolism (37). Much of the oral cortisone, however, is inactivated by oxidative metabolism (Fig. 33.9) before it can be converted to hydrocortisone in the liver. The pharmacokinetics for hydrocortisone acetate is indistinguishable from that of orally administered hydrocortisone. Oral hydrocortisone is completely absorbed, with a bioavailability of greater than 95% and a half-life of 1 to 2 hours (23). The metabolism of hydrocortisone (Fig. 33.9) has been previously described. Cortisone acetate is slowly absorbed from IM injection sites over a period of 24 to 48 hours and is reserved for patients who are unable to take the drug orally. The acetate ester derivative demonstrates increased stability and has a longer duration of action when administered by IM injection. Thus, smaller doses can be used. Similarly, hydrocortisone may be dispensed as its 21-acetate (hydrocortisone acetate), which is superior to cortisone acetate when injected intra-articularly. Systemic absorption of hydrocortisone acetate from intra-articular injection sites usually is complete within 24 to 48 hours. When administered intrarectally, hydrocortisone is poorly absorbed (38,39). 

Qvistgaard E, Christensen R, Torp-Pedersen S, Bliddal H. Intra-articular treatment of hip osteoarthritis a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline. Osteoarthritis Cartilage 2006 14 163-170. 

The fall in serum corticosteroid levels is established and of clinical importance in systemic treatment, but it seems unlikely to affect the response to steroids given topically or by inhalation, intra-articular injection or enema. The interaction can be accommodated in several ways ... 

Viscosupplementation via intra-articular hyaluronic acid injections is a conservative treatment modality to be used in conjunction with other conservative management modalities including activity modification, physical therapy, analgesics, nonsteroidal anti-inflammatories (NSAIDS), and intra-articular corticosteroid injections. It is only approved by the FDA for treating osteoarthritis of the knee. Off-label use has been reported for treatment of osteoarthritis affecting the earpometacarpal joints of the thumb, apophyseal joints of the lumbar spine, hip, ankle, and foot [1, 34, 40, 92, 101]. 

Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol 2010 29(4) 347-56. 

As with neuraxial injections, the concept of articular injection is to provide a high concentration of drug proximal to the location of the suspected origin of pain. Although intra-articular deposition certainly will produce a high concentration inside the joint, there is still a debate as to whether this is the major relevant site for pain treatment, as much of articular pain is believed to be mediated from structures outside the joint cavity, such as tendons, connective tissue, capsules, and muscle. Also, there is a concern that high concentration of intra-articular corticosteroid may have deleterious effects on cartilage and bone, as reported in some rare cases. 

Sarcoid bone involvement occurs in 1% to 13% of patients (213). It is most common in patients between the ages of 30 and 50 and in African Americans (213). Bone lesions are most common in the bones of the hands and feet however, the nasal bones, skull, and vertebrae may be affected (213). The lesions are often asymptomatic and routinely found on radiographic or MR studies. Radiologic findings usually show cystic or punched-out lesions (221). Sarcoidosis arthritis is usually treated with nonsteroidal anti-inflammatory agents (215), which are especially useful for acute sarcoid arthritis. Chronic destructive synovitis may require systemic corticosteroids or intra-articular injections (213). The addition of azathioprine or methotrexate may improve results and be corticosteroid sparing (213). 

Septic arthritis of the glenohumeral joint has predilection for very young infants or elderly patients with chronic debilitating disorders, such as diabetes, cirrhosis and alcoholism. The intra-articular injection of corticosteroids greatly increases the likelihood of infectious disease because of steroid-induced... 

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. 

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