Corticosteroids intraarticular

Intraarticular injection of corticosteroids or hyaluronan represents an alternative to oral agents for the treatment of joint pain.2S These modalities usually are reserved for patients unresponsive to other treatments because of the relative invasiveness of intraarticular injections compared with oral drugs, the small risk of infection, and the cost of the procedure. 

Pain and joint function have been evaluated frequently in clinical trials administering hyaluronan to patients with OA. Results are conflicting, with some suggesting dramatic improvements and others indicating no effect. In one controlled trial, hyaluronan injections relieved pain to a similar extent as oral NSAIDs.29 Hyaluronan provides greater pain relief for a longer time than intraarticular corticosteroids, but corticosteroids work more rapidly.29... 

Use of systemic corticosteroids is discouraged in patients with OA. However, in a subset of patients with an inflammatory component or knee effusion involving one or two joints, intraarticular corticosteroids can be useful as monotherapy or as an adjunct to analgesics. The affected joint can be aspirated and subsequently injected with a corticosteroid. The aspirate should be examined for the presence of crystalline formation and infection. A single joint should not be injected more than three to five times per year. 

When only one or two joints are affected, intraarticular corticosteroid injection can provide rapid relief with a relatively... 

Monitor patients receiving intraarticular corticosteroid injections for increased swelling or pain at the injection site. 

Intraarticular corticosteroid injections can provide relief, particularly when a joint effusion is present. Average doses for injection of large joints in adults are methylprednisolone acetate 20 to 40 mg or triamcinolone hexacetonide 10 to 20 mg. After aseptic aspiration of the effusion and corticosteroid injection, initial pain relief may occur within 24 to 72 hours, with peak relief occurring in about 1 week and lasting for 4 to 8 weeks. The patient should minimize joint activity and stress on the joint for several days after the injection. Therapy is generally limited to three or four injections per year because of the potential systemic effects of the drugs and because the need for more frequent injections indicates poor response to therapy. 

Chondroitin Sulfate and Glucosamine in OA therapy have efficacy comparable to placebo as showed by a National Institute of Health study. Intraarticular hyaluronic acid for pain relief is inferior compared to intraarticular corticosteroids. Temporary crepitus reduction or eradication may last several years in radiological stages I and II Knee OA with intraarticular hyaluronic acid. 

Persistent chronic gouty arthritis resistant to systemic therapy with colchicine and/or NSAIDs and/or corticosteroids is relieved by intraarticular corticosteroids. 

Gutierrez-Urena S, Ramos-Remus C. Persistent hiccups associated with intraarticular corticosteroid injection. J Rheumatol 1999 26(3) 760. 

Corticosteroids have a range of activity. They have potent antiinflammatory and immunosuppressive activity. Many synthetic drugs are available as corticosteroids. In appropriate doses, these are used as replacement therapy in adrenal insufficiency. The topical application of corticosteroids is safer when compared with systemic use. Corticosteroids should be used in smaller doses for the shortest duration of time. A high dose may be used for life-threatening syndromes or diseases. A tapering pattern of withdrawal should be followed to avoid complications of sudden withdrawal. Systemic therapy is indicated in a variety of conditions. These are administered by intraarticular injections with aseptic conditions for rheumatoid arthritis and osteoarthritis. In skin diseases, such as eczema, contact dermatitis, and psoriasis, corticosteroids are used topically. In some cases, steroids are combined with antimicrobial substances such as neomycin. 

Many drugs that have an anti-inflammatory action may also have other mechanisms of action. Corticosteroids are one of the most commonly administered classes of intraarticular medication in equine medicine. Hyaluronan (sodium hyaluronate, HA) is a natural component of the joint and its intraarticular use has anti-inflammatory actions and may have lubricating effects. Similarly dimethyl sulfoxide is used for both its anti-inflammatory and its antimicrobial actions. 

Table 7.1 Anti-Inflammatory potency and duration of action of corticosteroids used commonly for intraarticular administration...

Any time a needle is placed into the joint, a possibility exists for infection. The most commonly isolated organism following injection is Staph, aureus (Schneider et al 1992). There is evidence to suggest that the use of intraarticular corticosteroids... 

Postoperative analgesia from morphine has been shown to be the most effective if administered at the completion of the procedure (Brandsson et al 2000, Reuben et al 2001, Tetzlaff et al 2000). In these cases, it appears that the postoperative use of morphine allows the clinician to reduce both the level and the duration of other analgesics. This is not to say that the only potential benefit of morphine is in the postoperative patient. Morphine has also been shown to be of equivalent effect to corticosteroid administration in other forms of chronic arthritides (Keates et al 1999, Stein et al 1999). The reductions in inflammatory cell influx, reduced edema formation and analgesia provided with minimal systemic effects make intraarticular morphine a very attractive postoperative therapy. I most commonly use a combination of 5-15 mg morphine with 6 mg lidocaine for postoperative analgesia and have seen no untoward effects. The beneficial effects with respect to improved analgesia and ability to reduce the usage of NSAIDs remains to be proven. 

Pelletier J, Dibattista J A, Raynauld J et al 1995 The in vivo effects of intraarticular corticosteroid injections on cartilage lesions, stromelysin, interleukin-1 and oncogene protein synthesis in experimental osteoarthritis. Laboratory Investigation 72 578-586... 

Tulamo R M 1991 Comparison of high-performance liquid chromatography with a radiometric assay for determination of the effect of intraarticular administration of corticosteroid and saline solution on synoviai fluid hyaluronate concentration in horses. American Journal of Veterinary Research 52 1940-1944... 

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. 

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 intraarticular injection. 

Three treatments are available for patients with acute gouty arthritis. Colchicine is less favored now than in the past because its onset of action is slow and it invariably causes diarrhea. Nonsteroidal antiinflammatory drugs, which are currently favored, are rapidly effective but may have serious side effects. Corticosteroids, administered either intraarticularly or parenterally, are used increasingly in patients with monarticular gout, especially if oral drug therapy is not feasible. 

The HCP is administering an intraarticular corticosteroid mixed with lidocaine to a client with severe osteoarthritis in the right knee. Which statement by the client would warrant intervention by the nurse ... 

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

Bellamy N, Campbell J, Robinson V, et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2005 CD005328. 

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