Contact Information

Theodore Lowe, Ap #867-859
Sit Rd, Azusa New York

We Are Available 24/ 7. Call Now.

Side-effects of corticosteroid injections including joint
destruction

Marc Darrow MD,JD

Systemic and local side-effects of corticosteroid
injections including joint destruction

A patient will often come into our office with conflicting ideas
about cortisone injections. The patient will tell us that his/her
other doctors told them that cortisone injections are safe,
effective, and will help their pain, if used sparingly. But,
intuitively, the patient had doubts and concerns.

But as this patient continued to wait for a surgery, decisions
had to be made as to how much pain management would be needed to
“hold them over,” until the surgical date.

Corticosteroids are powerful anti-inflammatory substances. They
are not used to relieve pain, but rather, to reduce inflammation,
which in turn can lessen a patient’s level of discomfort.
Numerous studies over the years have shown that prolonged use of
cortisone will eventually cause degenerative joint disease in the
joints they are injected into.

UNDERSTANDING THE POSSIBLE COMPLICATIONS OF CORTISONE INJECTIONS.

A December 2020 paper in the medical journalRadiology (1)
says this:

  • Current management of osteoarthritis is primarily focused on
    symptom control.
  • Intra-articular corticosteroid injections are often used for
    pain management of hip and knee osteoarthritis in patients who have
    not responded to oral or topical analgesics.
  • “Recent case series suggested that negative structural
    outcomes including accelerated osteoarthritis progression,
    subchondral insufficiency fracture (stress fractures in the bone
    beneath cartilage), complications of pre-existing osteonecrosis,
    and rapid joint destruction (including bone
    loss)
     may be observed in patients who received
    Intra-articular corticosteroid injections .
  • The true cause and natural history of these
    complications are unclear and require further study.
     To
    determine the cause and natural history, large prospective studies
    evaluating the risk of osteoarthritis or joint destruction after
    Intra-articular corticosteroid injections are needed.

THE RESEARCH SURROUNDING CORTISONE INJECTION SIDE-EFFECTS IN CASES
OF OSTEOARTHRITIS HAVE BEEN GOING ON FOR DECADES. BUT WHAT ABOUT
ONE-TIME USE OR JUDICIOUS USE OF CORTISONE SPREAD OVER A
LONG-PERIOD OF TIME?

Let’s go back to 2010. Researchers wrote in BMC
musculoskeletal disorders,(2)
“In this literature review it was difficult to accurately
quantify the incidence of adverse effects after extra-articular
(around the joint) corticosteroid injection. Although one fatal
adverse event after an extra-articular corticosteroid injection was
reported, extra-articular corticosteroid injections are regularly
administered worldwide. In (this study) the incidence of major
adverse events  was up to 5.8%, ranging from
depigmentation and atrophy of the skin to
cellulitis
; generally speaking these adverse effects could
perhaps be classified as ‘relatively mild’. Based on these data
the administration of extra-articular corticosteroid injections
seems to be a ‘relatively safe’ intervention.â€

The side-effects were mostly limited to the skin area. But what
if the cortisone seeped into the bloodstream? Would it create whole
body side-effects? What would those side-effects be?

Here are excerpts
from Holland-Frei Cancer Medicine. 6th edition. Physiologic and
Pharmacologic Effects of Corticosteroids

Lorraine I. McKay, PhD and John A. Cidlowski,
PhD.

  • Corticosteroids are key regulators of whole-body homeostasis
    (balance) that provide an organism with the capacity to resist
    environmental changes and invasion of foreign substances. (These
    are changes and invasion that cause inflammation).
  • The effects of corticosteroids are widespread, including
    profound alterations in carbohydrate, protein, and lipid
    metabolism, and the modulation of electrolyte and water
    balance.
  • Corticosteroids affect all of the major systems of the body,
    including the cardiovascular, musculoskeletal, nervous, and immune
    systems.
  • Because so many systems are sensitive to corticosteroid levels,
    (the body exerts) tight regulatory control on the system.
  • The direct effects of corticosteroids are sometimes difficult
    to separate from their complex relationship with other hormones, in
    part due to the permissive action of low levels of corticosteroid
    on the effectiveness of other hormones, (it does not take much
    corticosteroid to do lot of hormonal and systematic changes in the
    body).
  • The effects of corticosteroids can be classified into two
    general categories: glucocorticoid (intermediary
    metabolism, inflammation, immunity, wound healing, myocardial, and
    muscle integrity) and mineralocorticoid (salt, water, and mineral
    metabolism).

In this article we will look at the glucocorticoid
effects.

  • Prolonged exposure to glucocorticoids leads to a
    diabetic-like state due
    to the increase in plasma glucose,
    while low glucocorticoid concentrations lead to hypoglycemia,
    decreased glycogen stores, and hypersensitivity to insulin.
  • The complex mechanisms for the side-effects of glucocorticoids
    are still unclear, but chronic administration can result in the
    atrophy of lymphatic tissue and muscle, osteoporosis, and
    thinning of the skin
    .
  • Glucocorticoids impact lipid metabolism. They act on
    redistribution of body fat in hypercorticism (also referred to as
    Cushing syndrome). Large doses of glucocorticoids lead to
    redistribution of fat to the upper trunk and face, with a
    concomitant loss of fat in the extremities.
  • Glucocorticoid effects on the kidney. The major renal
    complications of glucocorticoid therapy are nephrocalcinosis
    (increased calcium in the kidney), nephrolithiasis (kidney stones),
    and increased stone formation as a result of increased urinary
    calcium and uric acid.
  • High doses of glucocorticoids may cause peptic ulceration or
    aggravate preexisting ulcers.
  • Glucocorticoids influence many factors that modulate blood
    pressure.
  • there is evidence that glucocorticoids make atherosclerosis and
    thromboembolic complications more severe.
  • High glucocorticoid levels cause muscle wasting.
  • Chronic glucocorticoid administration results in induction of
    osteoporosis, a serious limiting factor in the clinical use of
    steroids.
  • Glucocorticoids slow wound healing by blocking the normal
    inflammatory reaction of breaking down and disorganizing
    collagen.

These are only a few of the things corticosteroids can do in a
hyper level state. But can an injection of cortisone in the knee
create any of these side effects?

In 1956 Dr. Martti Oka published a study in the Annals
of the Rheumatic Diseases
in which he examined the belief that
this new treatment (cortisone injections had only been extensively
used for 5 years at this time), was strictly a local treatment
(stayed in the joint) and had no systemic effects.

Dr. Oka did not find this to be true however he wrote:

  • “The results of these experiments show that
    intra-articularly injected hydrocortisone acetate is absorbed into
    the circulation to a considerable degree.
    †In fact the
    levels were so high that that systemic hormonal effects can be
    expected if large and frequent doses are used. It should be noted
    that these effects, Dr. Ok wrote, were transient in nature and
    lasted only 24 hours.

It was research like Dr. Oka’s that started to pave the way
for more judicial uses of cortisone over the many decades since. It
is also what lead many to believe that smaller doses of cortisone
would not cause systemic problems for more than a very brief period
of time.

Gradually, longer term effects were noted. Forty-two years after
Dr. Oka’s paper, in the same Annals of the Rheumatic Diseases,
(3)
doctors in the Netherlands recording these findings in 1998:

  • A systemic anti-inflammatory effect of glucocorticoid released
    from the joint found its way into the circulating blood.

How did it get there? In part by altering white
blood cells or altered leucocyte trafficking. This is an alteration
of the immune’s response to a hostile invader and/or suppression
of release of pro-inflammatory cytokines, these are inflammation
makers).

  • So by shutting off inflammation, the glucocorticoid snuck into
    the bloodstream and continued its anti-inflammatory effect
    throughout the body.

For how long and to what effect did this glucocorticoid impact
the body?

  • blood methylprednisolone concentration were measured for 96
    hours after intra-articular injection of methylprednisolone
    acetate.
  • Significant suppression of the hypothalamic-pituitary-adrenal
    axis persisted throughout this time.
  • After intra-articular injection of methylprednisolone, blood
    concentrations of glucocorticoid are sufficient to suppress
    monocyte TNF alpha release (systemic inflammation factors that are
    part of the healing cycle), for at least four days.

In 2014, Dr. George Habib (4)
who has authored many studies trying to find out if, how, and when
a cortisone injection into the knee has side-effects throughout the
body, found that injection of the glucosteroid methylprednisolone
acetate disrupted the hypothalamic-pituitary-adrenal axis in 25% of
subject patients receiving the injection for knee osteoarthritis.
These were patients who first failed to respond to nonsteroidal
anti-inflammatory medications and physical therapy. The disruption
was transient, lasting 2 – 4 weeks after the injection.

A disruption of the hypothalamic-pituitary-adrenal axis causes
secondary adrenal insufficiency, or Addison disease like symptoms
including dehydration, dizziness, fainting, fatigue,
lightheadedness, loss of appetite, low blood pressure, low blood
sugar, and excessive sweating.

These are symptoms created by free roaming corticosteroids in
the blood. From shutting down healing inflammation in the effected
joint to other areas of the body and a disruption of the
hypothalamic-pituitary-adrenal axis, corticosteroids, as Dr. Oka
pointed out in 1956, are not a localized event.

Research October 15, 2019. Steroid injections may lead to joint
collapse or hasten the need for total hip or knee replacement.

Here is a study published in the journal Radiology from the
Department of Radiology, Boston University School of Medicine
(5)
“Adverse joint events after intra-articular corticosteroid
injection, including accelerated osteoarthritis progression,
subchondral insufficiency fracture, complications of osteonecrosis,
and rapid joint destruction with bone loss, are becoming more
recognized by physicians, including radiologists, who may consider
adding these risks to the patient consent.â€

“What we wanted to do with our paper is to tell physicians and
patients to be careful, because these injections are likely not as
safe as we thought.â€


In the accompanying press release
issued by
the Radiological Society of North America, the publishers of the
journal Radiology, lead researcher of the study Ali Guermazi, M.D.,
Ph.D., professor of radiology and medicine at Boston University
School of Medicine, found that corticosteroid injections may be
associated with complications that potentially accelerate the
destruction of the joint and may hasten the need for total hip and
knee replacements.

“We’ve been telling patients that even if these
injections don’t relieve your pain, they’re not going to hurt
you,†Dr. Guermazi said. “But now we suspect that this is not
necessarily the case.â€

In a review of existing literature on complications after
treatment with corticosteroid injections, Dr. Guermazi and
colleagues identified four main adverse findings: accelerated
osteoarthritis progression with loss of the joint space,
subchondral insufficiency fractures (stress fractures that occur
beneath the cartilage), complications from osteonecrosis (death of
bone tissue), and rapid joint destruction including bone loss.

The researchers recommend careful scrutiny of patients
with mild or no osteoarthritis on X-rays who are referred for
injections to treat joint pain, especially when the pain is
disproportionate to the imaging findings. Prior research has shown
that these patients are at risk of developing rapid progressive
joint space loss or destructive osteoarthritis after injections.
Physicians may also want to reconsider a planned injection when the
patient has acute change in pain not explained by X-rays as some
underlying condition affecting joint health may be ongoing, the
researchers said. Most importantly, younger patients and patients
earlier in the course of the disease need to be told of the
potential consequences of a corticosteroid injection before they
receive it.

“Physicians do not commonly tell patients about the
possibility of joint collapse or subchondral insufficiency
fractures that may lead to earlier total hip or knee
replacement,†Dr. Guermazi said. “This information should be
part of the consent when you inject patients with intra-articular
corticosteroids.â€

With corticosteroid injections so widely used, the potential
implications of the study are enormous, according to Dr.
Guermazi.

“Intra-articular joint injection of steroids is a very common
treatment for osteoarthritis-related pain, but potential
aggravation of pre-existing conditions or actual side effects in a
subset of patients need to be explored further to better understand
the risks associated with it,†Dr. Guermazi said. “What we
wanted to do with our paper is to tell physicians and patients to
be careful, because these injections are likely not as safe as we
thought.â€

In a study in the Journal of the American Medical Association
(JAMA) doctors found that among patients with knee osteoarthritis,
an injection of a corticosteroid every three months over two years
resulted in significantly greater cartilage volume loss and
no significant difference in knee pain compared to patients who
received a placebo injection
.

Timothy E. McAlindon, D.M., M.P.H., of Tufts Medical Center,
Boston, and colleagues randomly assigned 140 patients with
symptomatic knee osteoarthritis with features of synovitis to
injections in the joint with the corticosteroid triamcinolone (70
patients) or saline (70 patients) every 12 weeks for two years. The
researchers found that injections with triamcinolone resulted in
significantly greater cartilage volume loss than did saline and no
significant difference on measures of pain. The saline group had
three treatment-related adverse events compared with five in the
triamcinolone group.(6)

In another study (7)
scientists released their findings on the damaging effects
of cortisone on cartilage and the inability of hyaluronic acid to
repair this damage when used in combination
. The idea of
combining cortisone and hyaluronic acid is that the intra-articular
injection of corticosteroids can treat the inflammatory pain of
arthritis and the hyaluronic acid can treat the deleterious effect
of these steroids on chondrocyte cells (it disintegrates
cartilage).

Hyaluronic acid injections has been suggested as a means to
counteract negative side effects through replenishment of synovial
fluid that can decrease pain in affected joints. However,
combination treatments of steroid and hyaluronic acid have not been
completely understood or standardized and are still a matter of
concern.(6) It may be better to avoid this treatment
because results are lacking is what the study
suggested.

Corticosteroids, like cortisone, are powerful anti-inflammatory
substances. They are not used to relieve pain, but rather reduce
inflammation, which in turn can lessen a patient’s level of
discomfort.

Examples of conditions for which local cortisone injections are
used include inflammation of a bursa (bursitis), a tendon
(tendonitis), and a joint (arthritis). Knee arthritis, hip
bursitis, painful foot conditions such as plantar fasciitis,
rotator cuff tendinitis and many other conditions may be treated
with cortisone injections.

In a study from Italy, researchers noted that local
glucocorticoids have shown positive results in some tendinopathies
but not in others. moreover, worsening of symptoms, reduction of
native healing stem cells in joints , and even spontaneous
tendon ruptures has been reported.
Several experimental
studies suggest that the direct action of glucocorticoids on
tendons is detrimental.(8)

Do you have questions? Ask Dr. Darrow

Please enable JavaScript in your browser to complete this
form.

Name *

First
Last
Email *
Phone Number *
Comment or Message *
Submit


A leading provider of
stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800)
300-9300
or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are
not FDA approved. We do not treat disease. We do not offer IV
treatments. There are no guarantees that this treatment will help
you. Prior to our treatment, seek advice from your medical
physician. Neither Dr. Darrow, nor any associate, offer medical
advice from this transmission. This information is offered for
educational purposes only. The transmission of this information
does not create a physician-patient relationship between you and
Dr. Darrow or any associate. We do not guarantee the accuracy,
completeness, usefulness or adequacy of any resource, information,
product, or process available from this transmission. We cannot be
responsible for the receipt of your email since spam filters and
servers often block their receipt. If you have a medical issue,
please call our office. If you have a medical emergency, please
call 911.

References:

1 Guermazi A, Neogi T, Katz JN, Kwoh CK,
Conaghan PG, Felson DT, Roemer FW. Intra-articular
Corticosteroid Injections for the Treatment of Hip and Knee
Osteoarthritis-related Pain: Considerations and Controversies with
a Focus on Imaging—Radiology Scientific Expert Panel
.
Radiology. 2020 Oct 20:200771.
2 Brinks, A., Koes, B. W., Volkers, A. C.,
Verhaar, J. A., & Bierma-Zeinstra, S. M. (2010).
Adverse effects of extra-articular corticosteroid injections: a
systematic review
. BMC Musculoskeletal Disorders,
11, 206. http://doi.org/10.1186/1471-2474-11-206
3 Steer JH, Ma DT, Dusci L, Garas G, Pedersen KE,
Joyce DA.
Altered leucocyte trafficking and suppressed tumour necrosis factor
α release from peripheral blood monocytes after intra-articular
glucocorticoid treatment
. Annals of the rheumatic diseases.
1998 Dec 1;57(12):732-7.
4 Habib G, Jabbour A, Artul S, Hakim G.
Intra-articular methylprednisolone acetate injection at the knee
joint and the hypothalamic–pituitary–adrenal axis: a randomized
controlled study
. Clinical rheumatology. 2014 Jan
1;33(1):99-103.
5 Andrew J. Kompel, Frank W. Roemer, Akira M.
Murakami, Luis E. Diaz, Michel D. Crema, Ali Guermazi
Intra-articular Corticosteroid Injections in the Hip and Knee:
Perhaps Not as Safe as We Thought?
Published Online:Oct 15 2019
https://doi.org/10.1148/radiol.2019190341
6 From the
JAMA news department
, May 16, 2017
7. Siengdee P, Radeerom T, Kuanoon S, Euppayo T,
Pradit W, Chomdej S, Ongchai S, Nganvongpanit K.
Effects of corticosteroids and their combinations with hyaluronanon
on the biochemical properties of porcine cartilage explants
.
BMC Vet Res. 2015 Dec 4;11(1):298. doi:
10.1186/s12917-015-0611-6.
8 Abate M, Salini V, Schiavone C, Andia I.

Clinical benefits and drawbacks of local corticosteroids injections
in tendinopathies.
Expert Opin Drug Saf. 2017
Mar;16(3):341-349. doi: 10.1080/14740338.2017.1276561. Epub 2016
Dec 28.

Marc Darrow MD,JD

Systemic and local side-effects of corticosteroid
injections including joint destruction

A patient will often come into our office with conflicting ideas
about cortisone injections. The patient will tell us that his/her
other doctors told them that cortisone injections are safe,
effective, and will help their pain, if used sparingly. But,
intuitively, the patient had doubts and concerns.

But as this patient continued to wait for a surgery, decisions
had to be made as to how much pain management would be needed to
“hold them over,” until the surgical date.

Corticosteroids are powerful anti-inflammatory substances. They
are not used to relieve pain, but rather, to reduce inflammation,
which in turn can lessen a patient’s level of discomfort.
Numerous studies over the years have shown that prolonged use of
cortisone will eventually cause degenerative joint disease in the
joints they are injected into.

UNDERSTANDING THE POSSIBLE COMPLICATIONS OF CORTISONE INJECTIONS.

A December 2020 paper in the medical journalRadiology (1)
says this:

  • Current management of osteoarthritis is primarily focused on
    symptom control.
  • Intra-articular corticosteroid injections are often used for
    pain management of hip and knee osteoarthritis in patients who have
    not responded to oral or topical analgesics.
  • “Recent case series suggested that negative structural
    outcomes including accelerated osteoarthritis progression,
    subchondral insufficiency fracture (stress fractures in the bone
    beneath cartilage), complications of pre-existing osteonecrosis,
    and rapid joint destruction (including bone
    loss)
     may be observed in patients who received
    Intra-articular corticosteroid injections .
  • The true cause and natural history of these
    complications are unclear and require further study.
     To
    determine the cause and natural history, large prospective studies
    evaluating the risk of osteoarthritis or joint destruction after
    Intra-articular corticosteroid injections are needed.

THE RESEARCH SURROUNDING CORTISONE INJECTION SIDE-EFFECTS IN CASES
OF OSTEOARTHRITIS HAVE BEEN GOING ON FOR DECADES. BUT WHAT ABOUT
ONE-TIME USE OR JUDICIOUS USE OF CORTISONE SPREAD OVER A
LONG-PERIOD OF TIME?

Let’s go back to 2010. Researchers wrote in BMC
musculoskeletal disorders,(2)
“In this literature review it was difficult to accurately
quantify the incidence of adverse effects after extra-articular
(around the joint) corticosteroid injection. Although one fatal
adverse event after an extra-articular corticosteroid injection was
reported, extra-articular corticosteroid injections are regularly
administered worldwide. In (this study) the incidence of major
adverse events  was up to 5.8%, ranging from
depigmentation and atrophy of the skin to
cellulitis
; generally speaking these adverse effects could
perhaps be classified as ‘relatively mild’. Based on these data
the administration of extra-articular corticosteroid injections
seems to be a ‘relatively safe’ intervention.â€

The side-effects were mostly limited to the skin area. But what
if the cortisone seeped into the bloodstream? Would it create whole
body side-effects? What would those side-effects be?

Here are excerpts
from Holland-Frei Cancer Medicine. 6th edition. Physiologic and
Pharmacologic Effects of Corticosteroids

Lorraine I. McKay, PhD and John A. Cidlowski,
PhD.

  • Corticosteroids are key regulators of whole-body homeostasis
    (balance) that provide an organism with the capacity to resist
    environmental changes and invasion of foreign substances. (These
    are changes and invasion that cause inflammation).
  • The effects of corticosteroids are widespread, including
    profound alterations in carbohydrate, protein, and lipid
    metabolism, and the modulation of electrolyte and water
    balance.
  • Corticosteroids affect all of the major systems of the body,
    including the cardiovascular, musculoskeletal, nervous, and immune
    systems.
  • Because so many systems are sensitive to corticosteroid levels,
    (the body exerts) tight regulatory control on the system.
  • The direct effects of corticosteroids are sometimes difficult
    to separate from their complex relationship with other hormones, in
    part due to the permissive action of low levels of corticosteroid
    on the effectiveness of other hormones, (it does not take much
    corticosteroid to do lot of hormonal and systematic changes in the
    body).
  • The effects of corticosteroids can be classified into two
    general categories: glucocorticoid (intermediary
    metabolism, inflammation, immunity, wound healing, myocardial, and
    muscle integrity) and mineralocorticoid (salt, water, and mineral
    metabolism).

In this article we will look at the glucocorticoid
effects.

  • Prolonged exposure to glucocorticoids leads to a
    diabetic-like state due
    to the increase in plasma glucose,
    while low glucocorticoid concentrations lead to hypoglycemia,
    decreased glycogen stores, and hypersensitivity to insulin.
  • The complex mechanisms for the side-effects of glucocorticoids
    are still unclear, but chronic administration can result in the
    atrophy of lymphatic tissue and muscle, osteoporosis, and
    thinning of the skin
    .
  • Glucocorticoids impact lipid metabolism. They act on
    redistribution of body fat in hypercorticism (also referred to as
    Cushing syndrome). Large doses of glucocorticoids lead to
    redistribution of fat to the upper trunk and face, with a
    concomitant loss of fat in the extremities.
  • Glucocorticoid effects on the kidney. The major renal
    complications of glucocorticoid therapy are nephrocalcinosis
    (increased calcium in the kidney), nephrolithiasis (kidney stones),
    and increased stone formation as a result of increased urinary
    calcium and uric acid.
  • High doses of glucocorticoids may cause peptic ulceration or
    aggravate preexisting ulcers.
  • Glucocorticoids influence many factors that modulate blood
    pressure.
  • there is evidence that glucocorticoids make atherosclerosis and
    thromboembolic complications more severe.
  • High glucocorticoid levels cause muscle wasting.
  • Chronic glucocorticoid administration results in induction of
    osteoporosis, a serious limiting factor in the clinical use of
    steroids.
  • Glucocorticoids slow wound healing by blocking the normal
    inflammatory reaction of breaking down and disorganizing
    collagen.

These are only a few of the things corticosteroids can do in a
hyper level state. But can an injection of cortisone in the knee
create any of these side effects?

In 1956 Dr. Martti Oka published a study in the Annals
of the Rheumatic Diseases
in which he examined the belief that
this new treatment (cortisone injections had only been extensively
used for 5 years at this time), was strictly a local treatment
(stayed in the joint) and had no systemic effects.

Dr. Oka did not find this to be true however he wrote:

  • “The results of these experiments show that
    intra-articularly injected hydrocortisone acetate is absorbed into
    the circulation to a considerable degree.
    †In fact the
    levels were so high that that systemic hormonal effects can be
    expected if large and frequent doses are used. It should be noted
    that these effects, Dr. Ok wrote, were transient in nature and
    lasted only 24 hours.

It was research like Dr. Oka’s that started to pave the way
for more judicial uses of cortisone over the many decades since. It
is also what lead many to believe that smaller doses of cortisone
would not cause systemic problems for more than a very brief period
of time.

Gradually, longer term effects were noted. Forty-two years after
Dr. Oka’s paper, in the same Annals of the Rheumatic Diseases,
(3)
doctors in the Netherlands recording these findings in 1998:

  • A systemic anti-inflammatory effect of glucocorticoid released
    from the joint found its way into the circulating blood.

How did it get there? In part by altering white
blood cells or altered leucocyte trafficking. This is an alteration
of the immune’s response to a hostile invader and/or suppression
of release of pro-inflammatory cytokines, these are inflammation
makers).

  • So by shutting off inflammation, the glucocorticoid snuck into
    the bloodstream and continued its anti-inflammatory effect
    throughout the body.

For how long and to what effect did this glucocorticoid impact
the body?

  • blood methylprednisolone concentration were measured for 96
    hours after intra-articular injection of methylprednisolone
    acetate.
  • Significant suppression of the hypothalamic-pituitary-adrenal
    axis persisted throughout this time.
  • After intra-articular injection of methylprednisolone, blood
    concentrations of glucocorticoid are sufficient to suppress
    monocyte TNF alpha release (systemic inflammation factors that are
    part of the healing cycle), for at least four days.

In 2014, Dr. George Habib (4)
who has authored many studies trying to find out if, how, and when
a cortisone injection into the knee has side-effects throughout the
body, found that injection of the glucosteroid methylprednisolone
acetate disrupted the hypothalamic-pituitary-adrenal axis in 25% of
subject patients receiving the injection for knee osteoarthritis.
These were patients who first failed to respond to nonsteroidal
anti-inflammatory medications and physical therapy. The disruption
was transient, lasting 2 – 4 weeks after the injection.

A disruption of the hypothalamic-pituitary-adrenal axis causes
secondary adrenal insufficiency, or Addison disease like symptoms
including dehydration, dizziness, fainting, fatigue,
lightheadedness, loss of appetite, low blood pressure, low blood
sugar, and excessive sweating.

These are symptoms created by free roaming corticosteroids in
the blood. From shutting down healing inflammation in the effected
joint to other areas of the body and a disruption of the
hypothalamic-pituitary-adrenal axis, corticosteroids, as Dr. Oka
pointed out in 1956, are not a localized event.

Research October 15, 2019. Steroid injections may lead to joint
collapse or hasten the need for total hip or knee replacement.

Here is a study published in the journal Radiology from the
Department of Radiology, Boston University School of Medicine
(5)
“Adverse joint events after intra-articular corticosteroid
injection, including accelerated osteoarthritis progression,
subchondral insufficiency fracture, complications of osteonecrosis,
and rapid joint destruction with bone loss, are becoming more
recognized by physicians, including radiologists, who may consider
adding these risks to the patient consent.â€

“What we wanted to do with our paper is to tell physicians and
patients to be careful, because these injections are likely not as
safe as we thought.â€


In the accompanying press release
issued by
the Radiological Society of North America, the publishers of the
journal Radiology, lead researcher of the study Ali Guermazi, M.D.,
Ph.D., professor of radiology and medicine at Boston University
School of Medicine, found that corticosteroid injections may be
associated with complications that potentially accelerate the
destruction of the joint and may hasten the need for total hip and
knee replacements.

“We’ve been telling patients that even if these
injections don’t relieve your pain, they’re not going to hurt
you,†Dr. Guermazi said. “But now we suspect that this is not
necessarily the case.â€

In a review of existing literature on complications after
treatment with corticosteroid injections, Dr. Guermazi and
colleagues identified four main adverse findings: accelerated
osteoarthritis progression with loss of the joint space,
subchondral insufficiency fractures (stress fractures that occur
beneath the cartilage), complications from osteonecrosis (death of
bone tissue), and rapid joint destruction including bone loss.

The researchers recommend careful scrutiny of patients
with mild or no osteoarthritis on X-rays who are referred for
injections to treat joint pain, especially when the pain is
disproportionate to the imaging findings. Prior research has shown
that these patients are at risk of developing rapid progressive
joint space loss or destructive osteoarthritis after injections.
Physicians may also want to reconsider a planned injection when the
patient has acute change in pain not explained by X-rays as some
underlying condition affecting joint health may be ongoing, the
researchers said. Most importantly, younger patients and patients
earlier in the course of the disease need to be told of the
potential consequences of a corticosteroid injection before they
receive it.

“Physicians do not commonly tell patients about the
possibility of joint collapse or subchondral insufficiency
fractures that may lead to earlier total hip or knee
replacement,†Dr. Guermazi said. “This information should be
part of the consent when you inject patients with intra-articular
corticosteroids.â€

With corticosteroid injections so widely used, the potential
implications of the study are enormous, according to Dr.
Guermazi.

“Intra-articular joint injection of steroids is a very common
treatment for osteoarthritis-related pain, but potential
aggravation of pre-existing conditions or actual side effects in a
subset of patients need to be explored further to better understand
the risks associated with it,†Dr. Guermazi said. “What we
wanted to do with our paper is to tell physicians and patients to
be careful, because these injections are likely not as safe as we
thought.â€

In a study in the Journal of the American Medical Association
(JAMA) doctors found that among patients with knee osteoarthritis,
an injection of a corticosteroid every three months over two years
resulted in significantly greater cartilage volume loss and
no significant difference in knee pain compared to patients who
received a placebo injection
.

Timothy E. McAlindon, D.M., M.P.H., of Tufts Medical Center,
Boston, and colleagues randomly assigned 140 patients with
symptomatic knee osteoarthritis with features of synovitis to
injections in the joint with the corticosteroid triamcinolone (70
patients) or saline (70 patients) every 12 weeks for two years. The
researchers found that injections with triamcinolone resulted in
significantly greater cartilage volume loss than did saline and no
significant difference on measures of pain. The saline group had
three treatment-related adverse events compared with five in the
triamcinolone group.(6)

In another study (7)
scientists released their findings on the damaging effects
of cortisone on cartilage and the inability of hyaluronic acid to
repair this damage when used in combination
. The idea of
combining cortisone and hyaluronic acid is that the intra-articular
injection of corticosteroids can treat the inflammatory pain of
arthritis and the hyaluronic acid can treat the deleterious effect
of these steroids on chondrocyte cells (it disintegrates
cartilage).

Hyaluronic acid injections has been suggested as a means to
counteract negative side effects through replenishment of synovial
fluid that can decrease pain in affected joints. However,
combination treatments of steroid and hyaluronic acid have not been
completely understood or standardized and are still a matter of
concern.(6) It may be better to avoid this treatment
because results are lacking is what the study
suggested.

Corticosteroids, like cortisone, are powerful anti-inflammatory
substances. They are not used to relieve pain, but rather reduce
inflammation, which in turn can lessen a patient’s level of
discomfort.

Examples of conditions for which local cortisone injections are
used include inflammation of a bursa (bursitis), a tendon
(tendonitis), and a joint (arthritis). Knee arthritis, hip
bursitis, painful foot conditions such as plantar fasciitis,
rotator cuff tendinitis and many other conditions may be treated
with cortisone injections.

In a study from Italy, researchers noted that local
glucocorticoids have shown positive results in some tendinopathies
but not in others. moreover, worsening of symptoms, reduction of
native healing stem cells in joints , and even spontaneous
tendon ruptures has been reported.
Several experimental
studies suggest that the direct action of glucocorticoids on
tendons is detrimental.(8)

Do you have questions? Ask Dr. Darrow

Please enable JavaScript in your browser to complete this
form.

Name *

First
Last
Email *
Phone Number *
Comment or Message *
Submit


A leading provider of
stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800)
300-9300
or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are
not FDA approved. We do not treat disease. We do not offer IV
treatments. There are no guarantees that this treatment will help
you. Prior to our treatment, seek advice from your medical
physician. Neither Dr. Darrow, nor any associate, offer medical
advice from this transmission. This information is offered for
educational purposes only. The transmission of this information
does not create a physician-patient relationship between you and
Dr. Darrow or any associate. We do not guarantee the accuracy,
completeness, usefulness or adequacy of any resource, information,
product, or process available from this transmission. We cannot be
responsible for the receipt of your email since spam filters and
servers often block their receipt. If you have a medical issue,
please call our office. If you have a medical emergency, please
call 911.

References:

1 Guermazi A, Neogi T, Katz JN, Kwoh CK,
Conaghan PG, Felson DT, Roemer FW. Intra-articular
Corticosteroid Injections for the Treatment of Hip and Knee
Osteoarthritis-related Pain: Considerations and Controversies with
a Focus on Imaging—Radiology Scientific Expert Panel
.
Radiology. 2020 Oct 20:200771.
2 Brinks, A., Koes, B. W., Volkers, A. C.,
Verhaar, J. A., & Bierma-Zeinstra, S. M. (2010).
Adverse effects of extra-articular corticosteroid injections: a
systematic review
. BMC Musculoskeletal Disorders,
11, 206. http://doi.org/10.1186/1471-2474-11-206
3 Steer JH, Ma DT, Dusci L, Garas G, Pedersen KE,
Joyce DA.
Altered leucocyte trafficking and suppressed tumour necrosis factor
α release from peripheral blood monocytes after intra-articular
glucocorticoid treatment
. Annals of the rheumatic diseases.
1998 Dec 1;57(12):732-7.
4 Habib G, Jabbour A, Artul S, Hakim G.
Intra-articular methylprednisolone acetate injection at the knee
joint and the hypothalamic–pituitary–adrenal axis: a randomized
controlled study
. Clinical rheumatology. 2014 Jan
1;33(1):99-103.
5 Andrew J. Kompel, Frank W. Roemer, Akira M.
Murakami, Luis E. Diaz, Michel D. Crema, Ali Guermazi
Intra-articular Corticosteroid Injections in the Hip and Knee:
Perhaps Not as Safe as We Thought?
Published Online:Oct 15 2019
https://doi.org/10.1148/radiol.2019190341
6 From the
JAMA news department
, May 16, 2017
7. Siengdee P, Radeerom T, Kuanoon S, Euppayo T,
Pradit W, Chomdej S, Ongchai S, Nganvongpanit K.
Effects of corticosteroids and their combinations with hyaluronanon
on the biochemical properties of porcine cartilage explants
.
BMC Vet Res. 2015 Dec 4;11(1):298. doi:
10.1186/s12917-015-0611-6.
8 Abate M, Salini V, Schiavone C, Andia I.

Clinical benefits and drawbacks of local corticosteroids injections
in tendinopathies.
Expert Opin Drug Saf. 2017
Mar;16(3):341-349. doi: 10.1080/14740338.2017.1276561. Epub 2016
Dec 28.

Share:

administrator