Preservative Free Steroids for ESIs

[huskydoc]

Our institution has preservative free (PF) - Dexamethasone which we use for our Lumbar TFESI, however our triamcinolone (acetonide), which we are using in Cervical and Lumbar interlaminar ESI, is not fully preservative free and has benzyl alcohol in it.
We recently had a switch in suppliers and we received Dex with benzyl alcohol and I asked to get some of the PF stuff.

Do people have (non-compounding pharmacy) kenalog that is truly preservative free?

If not, do you care? Do you think it matters to have the Dex with benzyl alcohol.

None of our steroids have methyl-paraben, but I had previously neglected to really dig deeper on our kenalog options. Before starting a ruckus, I wanted to query the group.

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[lobelsteve]

Dont care and neither does ISIS. if you go IT with ESI then you must abort if using preservative containing steroids.

 

[emd123]

Pretty sure "preservative free" kenalog doesn't exist. Same with betamethasone, unless you get compounded, which I'd never do after the compounded DepoMedrol deaths. I think the single dose dex is as close as you're going to get, but like Steve said, unless you go intrathecal (which you're going to abort anyways) then it doesn't matter that much. They have to put some amount of preservative to prevent bacterial and fungal formation in the vial, and I'm not so sure that's a bad thing.

 

[bedrock]

Pretty sure "preservative free" kenalog doesn't exist. Same with betamethasone, unless you get compounded, which I'd never do after the compounded DepoMedrol deaths. I think the single dose dex is as close as you're going to get, but like Steve said, unless you go intrathecal (which you're going to abort anyways) then it doesn't matter that much. They have to put some amount of preservative to prevent bacterial and fungal formation in the vial, and I'm not so sure that's a bad thing.

Agree with EMD. The only preservative-free steroid made by a major manufacturer is dexamethasone, and even then you have to check that you order the right one.

There is no preservative free kenalog, depomedrol, or celestone. The only way to get those is by compounding, which is clearly not worth the infection risk to the patient, or the liability risk to you.

The one thing I would recommend is to buy the single dose vials of whichever particulate steroid you use for spinal injections.The actual amount of preservative is lower in a single dose vial than in a multi-dose vial which is designed to stay half-used on a shelf for while.
Using single dose vials reduces the relative risk of some kind of reaction to the preservative, since there is less of it in single dose vials. Additionally, ISIS and the CDC recommend you use single dose steroid vials when performing neuroaxial injections anyway.

 

[oreosandsake]

doesn't really solve your problem but interesting

Anesth Analg. 2011 Dec;113(6):1487-9. doi: 10.1213/ANE.0b013e31823526d7. Epub 2011 Sep 29.
Enhancing the relative safety of intentional or unintentional intrathecal methylprednisolone administration by removing polyethylene glycol.
Candido KD1, Knezevic I, Mukalel J, Knezevic NN.
Author information

Abstract
BACKGROUND:
Previous studies have shown that intrathecal methylprednisolone is a very effective treatment for postherpetic neuralgia. However, widespread use of intrathecal methylprednisolone is limited by the presence of polyethylene glycol (PEG) as a preservative in the commercial formulation. In this study, we are proposing a method to reduce the concentration of PEG in the methylprednisolone acetate (MPA) suspension by inverting a vial before sterilely aspirating the contents into a syringe for subsequent injection. The purpose of this brief study was to precisely quantify the concentration of PEG in the MPA suspension.

METHODS:
Single-dose vials containing 80 mg of MPA suspension were inverted to promote partition of the PEG away from the steroid component. After achieving 2 phases, we carefully extracted and aspirated only the steroid component. We kept the vials inverted for different time points (from 0 to 480 minutes), and we measured the concentration of PEG and methylprednisolone by using liquid chromatography and mass spectrometry. We also measured the pH of samples by using the pH meter for small samples.

RESULTS:
The 1-way analysis of variance with post hoc analysis and Bonferroni correction showed statistically significant differences (P < 0.0001) between baseline concentrations and concentrations after inverting the vials for different times. We removed a minimum of 78% of PEG (the Bonferroni-corrected lower confidence limit for overall reduction in PEG) by keeping the vials inverted from 2 to 4 hours, and the average amount removed was 85% per vial. However, we did not change the concentration of methylprednisolone or the pH of the solution.

CONCLUSIONS:
We believe that by decreasing the PEG concentration using our method, MPA-related complications will potentially be reduced, and this should be considered in patients with postherpetic neuralgia refractory to other treatments who might be candidates for repeated intrathecal injections.

 

[clubdeac]

Wrong you all are!! There is PF kenalog! It's used by optho's and is called Triesence. I used it at the VA spa. Probably costs a buttload so nobody uses it in the real world

 

[Aether2000]

In light of the multiple compounding pharmacy fiascos and potential infection of over 10,000 people in the US, the use of any injectable compounded steroid (especially if preservative free) is simply indefensible in court. If there are any complications, whether related to the compounded steroid or not, the physician will be implicated for malpractice. BTW, PEG is not a preservative, it is a suspensory agent.

 

[bedrock]

Wrong you all are!! There is PF kenalog! It's used by optho's and is called Triesence. I used it at the VA spa. Probably costs a buttload so nobody uses it in the real world

True. I remember you mentioning that a year ago. It is very expensive and unrealistic for PP.
And it's triamcinolone, which has an undeserved FDA warning against epidural use.

 

[Pacman27]

I thought it was concluded that the amount of preservatives is negligible to be the cause arachnoiditis. Not advocating that you should injection intrathecal, but I believe the risks of preservatives injected inadvertently IT outweighs the risk of PF solutions

 

[lobelsteve]

I thought it was concluded that the amount of preservatives is negligible to be the cause arachnoiditis. Not advocating that you should injection intrathecal, but I believe the risks of preservatives injected inadvertently IT outweighs the risk of PF solutions

I can control IT vs epidural. I cannot control QC at a compounding pharmacy.