Steroid Injections while on Oral Steroids

[jewwithguitar]

I have been receiving referrals from Ortho for injections (IA Hip, ESI) for patients who are already taking an oral steroid for the presenting issue (Medrol Dose Pack or 5-10 mg Presnisone). I have been rescheduling these injections out 2 weeks after completion of oral steroid.

Similarly, I receive referrals for injections in patients who have just received a steroid injection (IA Hip, GTB, etc) 2-3 days prior. I am similarly resheduling these patients 2 weeks out.

Patients are sometimes upset and Ortho does not seem to understand my decision-making. Am I being overly cautious or appropriate? What is your usual course of action in these situations?

---

Members don't see this ad.

 

[lobelsteve]

Systemic corticosteroids for radicular and non-radicular low back pain - PubMed

Systemic corticosteroids appear to be slightly effective at improving short-term pain and function in people with radicular low back pain not due to spinal stenosis, and might slightly improve long-term function. The effects of systemic corticosteroids in people with non-radicular low back pain...

pubmed.ncbi.nlm.nih.gov

Pharmacotherapy for Spine-Related Pain in Older Adults - PubMed Corticosteroids have the least evidence for treating nonspecific back pain.

The Effectiveness of Oral Corticosteroids for Management of Lumbar Radiating Pain: Randomized, Controlled Trial Study This study supports steroids but pain was about 4.8 to start and went to 2.0 in steroid group and 3.0 in Lyrica or gabapentin group. A poor study with less than 10% enrollment and not well controlled.

 

[lobelsteve]

Oh, and I would do my shot regardless of the mistakes of others. Consult notes should reflect that steroids for back or back and leg pain are dogma and not adequately supported in the literature. Might save the next patient from suboptimal treatment.

 

[willabeast]

Would be hesitant to do an elective procedure within days of another procedure. If things go wrong it will be a circus. If ortho is giving you grief ask Rheumatology for advice and document it. Ortho has to respect Rheum as it is a major referral source. BTW you in a band?

 

[jewwithguitar]

Thanks for your thoughts guys. Just looking to see what others have been doing in situations like this as I have been operating under the concept that it takes 2 weeks for the effects of exogenous steroid on the HPA axis to dissipate. Not a bad idea to discuss this with Rheumatology (or even Endocrinology) too.

Steve, I agree with you on the oral steroids, but we know that Orthopods do not tend to listen to other's suggestions well, no matter how factual they may be. There has been little tracking of how much steroids these patients are getting over time and I am trying to do the right thing for these patients, but also avoid pissing off referral sources in the process.

 

[oreosandsake]

DC the oral steroids
replace with injection
re-schedule is reasonable

not saying it's the best for the patients but some rheum will put patients with RA on long term oral prednisone... dosages way higher than the dose pak and whatever your injection might contain

 

[DrSpine]

Oh, and I would do my shot regardless of the mistakes of others. Consult notes should reflect that steroids for back or back and leg pain are dogma and not adequately supported in the literature. Might save the next patient from suboptimal treatment.

You'd have to word that pretty good because if it's a referring Physician who gives you a lot of patients, such a note essentially ripping them for dogma would burn bridges pretty badly and end that referral line quick.

 

[lobelsteve]

You'd have to word that pretty good because if it's a referring Physician who gives you a lot of patients, such a note essentially ripping them for dogma would burn bridges pretty badly and end that referral line quick.

You haven't met me. Baseline personality is a jerk. Most days I am worse.

 

[TIVAndy]

i'm booking out 2-3 weeks so i just tell them to stop oral steroids.

 

[Ducttape]

if the patient is on a transient course of steroids, then it is prudent to stop as soon as you administer the injection.



dont stop steroids if it is being used long term for whatever medical condition. that needs to be tapered.