A1c and injections

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oreosandsake

oreosandsake

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what are your policies re this if they aren't going to get steroids?

let's say they have A1c of 11+

would you do TPI? MBB? RFA?

what if the story was complicated by chronic poorly healing wounds in the limbs?

curious what people's thresholds are and what a1c you'd inject at.
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oreosandsake said:
what are your policies re this if they aren't going to get steroids?

let's say they have A1c of 11+

would you do TPI? MBB? RFA?

what if the story was complicated by chronic poorly healing wounds in the limbs?

curious what people's thresholds are and what a1c you'd inject at.
Click to expand...
Our cutoff is 250 BS at the time of procedure. We don't have a formal policy about A1c and steroids but should probably think of that. I would have to have a pretty convincing story to not consider a 27g needle for TPIs if I felt clinically indicated. If they are getting labs, insulin, (needle pokes). without issues I would find it hard to say no.
 
VA Ortho limits surgeries to less than 8.6 and we have adopted this for any steroid injection unless severe pain and recent glucose has been 120 or less
 
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A1c 8.5 or less.

Random glucose is less useful but I generally use 250 as a cutoff but if it's a little elevated above that and A1c is otw below 8.5 I'll make exceptions (and usually won't use a steroid).

oreosandsake said:
what if the story was complicated by chronic poorly healing wounds in the limbs?

curious what people's thresholds are and what a1c you'd inject at.
Click to expand...

It would tell me I'm dealing with bad protoplasm and would tread cautiously if at all.
 
au bon pain said:
A1c 8.5 or less.

Random glucose is less useful but I generally use 250 as a cutoff but if it's a little elevated above that and A1c is otw below 8.5 I'll make exceptions (and usually won't use a steroid).



It would tell me I'm dealing with bad protoplasm and would tread cautiously if at all.
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I do about the same, A1c above 9 or glucose above 250 I won't do steroid. A1c between 8-9 i may or may not.

With an A1c that high they need to get serious about diabetes control, and not doing the injection may help reinforce that.
 
I bet there's a correlation between those who routinely check labs for an injxn and those who give IV sedation for the same procedures.
 
TPI, MBB, RFA - i dont consider A1C for these. not that i do a lot of TPI.

if there is evidence of poor healing clinically, that means a lot more to me than the current A1C. if a person has severe lower extremity ulcerations, then they shouldnt have a tpi or other procedure.

after all, these people get IVs and blood draws all the time without deleterious side effects. and i guarantee the phlebotomists are not as fastidious about sterile prep than i am.
 
i dont check.

dont even really care if they are diabetic.

if sugars are routinely out of control and they are working with end or have obvious ulcerations, etc, ill wait until they are under better control. that happens about 2x/decade
 
Post op glucose impacts wound healing so same 8.5 cutoff for implants.
 
MitchLevi said:
I bet there's a correlation between those who routinely check labs for an injxn and those who give IV sedation for the same procedures.
Click to expand...

Nope. I’ve done 0 cases with IV sedation in the last year and almost never offer it.

I don’t order A1Cs or go hunting but the majority of patients I see have labs done in the same health system connected to my EMR so I see the results. IMHO choosing to ignore that part of the patients chart would be wrong.
 
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I don't measure A1C, but will review if in chart. I don't have an A1C cutoff for injections, but will cancel steroid injections if glucose is greater than 250. I'm okay doing MBB/RF since I don't use steroids for those.

For implants, I was the A1C to be under control, but I don't do many implants. Ortho literature is for insertion of hardware and the associated post-op infection as well as wound healing. A low A1C makes sense for anytime you want to insert a foreign device.
 
Not checking labs before an implant is a stray from standard of care IMO.
 
I feel like people are all over the map with labs. I only get for SCS (including trial), kypho, Intracept. CBC, UA, coags looking for occult infection and bleeding risk. Plenty don't do this and I don't know if I'm opening a can of worms sometimes.
 
I stopped offering steroids to pts with an A1c>8.5 after I had a few brittle diabetics end up in the ED with DKA and hyperosmolar hyperglycemia. I'll give half my normal dose (40 mg Kenalog equivalent is my normal, so 20 mg) to diabetics in the 7-8.5 range the first time around to see how they respond.
 
Ligament said:
Wut is A1c? I have not looked at that since residency...
Click to expand...

Patient came in asking for TPI

Open wounds in the legs

Uncontrolled dm2

Last A1c 12

Let’s say no wounds. Would you still?
 
oreosandsake said:
Patient came in asking for TPI

Open wounds in the legs

Uncontrolled dm2

Last A1c 12

Let’s say no wounds. Would you still?
Click to expand...
TPI is exclusively local and I would do it. Shouldn't be putting steroid in the TPI.
 
oreosandsake said:
Yeah I don’t out steroid in there… but man a1c of 12. Non healing Open wounds….
Click to expand...

As you describe this pt, it seems your goal is not playing to win but rather not to lose. I that tact makes sense

Overall would the patient be better off getting TPIs now?

Or getting them as a reward for lowering their A1c to sub-maple syrup levels?

And any whisp of neuropathic pain give ala in the interim to give them “something” and keep them engaged.
 
au bon pain said:
As you describe this pt, it seems your goal is not playing to win but rather not to lose. I that tact makes sense

Overall would the patient be better off getting TPIs now?

Or getting them as a reward for lowering their A1c to sub-maple syrup levels?

And any whisp of neuropathic pain give ala in the interim to give them “something” and keep them engaged.
Click to expand...

i didn't check his labs but saw he had wounds and multiple wound care appts in the emr

when i spoke with him he said he checks his BS daily and they run 150s... so i thought, ok, sure let's schedule for tpi

then i checked his chart and a1c from within 2 weeks prior was 12. you don't get an a1c of 12 with fasting BS of 150.

my cutoff for steroids is a1c of 8. i have had a few brittle IDDM2 get their sugars up to 400-500s after CSI even with low a1c and strict monitoring at home with sliding scale. i was just curious how people handle non steroid injections, non implants etc.

so once i saw the a1c of a dozen i cancelled the procedure. not worth the risk...
 
oreosandsake said:
what are your policies re this if they aren't going to get steroids?

let's say they have A1c of 11+

would you do TPI? MBB? RFA?

what if the story was complicated by chronic poorly healing wounds in the limbs?

curious what people's thresholds are and what a1c you'd inject at.
Click to expand...
Steroids are not mandatory for any of those procedures, so A1C and glucose are of no concern. Just do them without steroids. I do all my mob's and RFAs without steroids anyways. TPIs only with steroids sometimes (usually not).
 
oreosandsake said:
Patient came in asking for TPI
Click to expand...
seems like a lot more issues to worry about than myofascial pain, but it is a risk benefit analysis that you appropriately individualized.

if you really think the myofascial pain is limiting his ability to get his HgA1C down to a human level, then a non-steroid injection is reasonable.

heck, if it improved his HgA1C down to single digits, you could probably publish it as a case report.



and about now is when drusso posts how the PRP in such a diabetic is extra special good sauce for healing of all sorts of conditions...
 
new patient i saw today. chronic knee pain. bad tricompartment disease.

ortho had been giving him knee steroid injections. after last one, which did help, he referred to me.



i will not be giving any steroid injections:
high hg.GIF


she said her BG this morning was 150.....

yeah okay.
 
Ducttape said:
new patient i saw today. chronic knee pain. bad tricompartment disease.

ortho had been giving him knee steroid injections. after last one, which did help, he referred to me.



i will not be giving any steroid injections:
View attachment 373121

she said her BG this morning was 150.....

yeah okay.
Click to expand...
If I were an Ozempic KOL, I'd be thrilled (@drusso)
 
lobelsteve said:
If I were an Ozempic KOL, I'd be thrilled (@drusso)
Click to expand...

Targeting the GLP-1/GLP-1R axis to treat osteoarthritis: A new opportunity? - PMC

Osteoarthritis (OA) is a degenerative joint disease affecting millions of people worldwide. In OA, chondrocytes, synovial cells and other joint cells become activated when exposed to an abnormal environment, including mechanical stress, inflammatory ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

J Orthop Translat. 2022 Feb 25;32:121-129.
doi: 10.1016/j.jot.2022.02.001. eCollection 2022 Jan.

Targeting the GLP-1/GLP-1R axis to treat osteoarthritis: A new opportunity?​

C Meurot 1, C Jacques 2, C Martin 1, L Sudre 1, J Breton 1, R Rattenbach 1 3, K Bismuth 1, F Berenbaum 3 4
Affiliations expand
Free PMC article

Abstract​

Osteoarthritis (OA) is a degenerative joint disease affecting millions of people worldwide. In OA, chondrocytes, synovial cells and other joint cells become activated when exposed to an abnormal environment, including mechanical stress, inflammatory cytokines or disorganization of matrix proteins. Several analogues of the hormones called incretins have been developed and are used notably for treating type 2 diabetes mellitus. Data has accumulated to suggest that incretinomimetics, which bind to the glucagon-like peptide-1 receptor (GLP-1R), have beneficial pleiotropic effects such as immunomodulation, anti-inflammation and neuronal protection. Thus, because of their anti-inflammatory properties, GLP-1-based therapies could benefit OA patients. This review focuses on the GLP-1R pathway, molecular mechanisms and phenotypes related to OA pathogenesis.
The translational potential of this article: The search for new therapeutic targets to treat people suffering from OA remains urgent as there is currently no disease-modifyingtherapy available for this disease. This review discusses how GLP-1 analogues could be potential DMOADs for treating OA thanks to their anti-inflammatory, immunoregulatory and differentiation properties.
Keywords: Cartilage; Glucagon-like peptide-1 (GLP-1); Glucagon-like peptide-1 receptor (GLP-1R); Liraglutide; Osteoarthritis; Synovial tissue.
 
drusso said:

Targeting the GLP-1/GLP-1R axis to treat osteoarthritis: A new opportunity? - PMC

Osteoarthritis (OA) is a degenerative joint disease affecting millions of people worldwide. In OA, chondrocytes, synovial cells and other joint cells become activated when exposed to an abnormal environment, including mechanical stress, inflammatory ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

J Orthop Translat. 2022 Feb 25;32:121-129.
doi: 10.1016/j.jot.2022.02.001. eCollection 2022 Jan.

Targeting the GLP-1/GLP-1R axis to treat osteoarthritis: A new opportunity?​

C Meurot 1, C Jacques 2, C Martin 1, L Sudre 1, J Breton 1, R Rattenbach 1 3, K Bismuth 1, F Berenbaum 3 4
Affiliations expand
Free PMC article

Abstract​

Osteoarthritis (OA) is a degenerative joint disease affecting millions of people worldwide. In OA, chondrocytes, synovial cells and other joint cells become activated when exposed to an abnormal environment, including mechanical stress, inflammatory cytokines or disorganization of matrix proteins. Several analogues of the hormones called incretins have been developed and are used notably for treating type 2 diabetes mellitus. Data has accumulated to suggest that incretinomimetics, which bind to the glucagon-like peptide-1 receptor (GLP-1R), have beneficial pleiotropic effects such as immunomodulation, anti-inflammation and neuronal protection. Thus, because of their anti-inflammatory properties, GLP-1-based therapies could benefit OA patients. This review focuses on the GLP-1R pathway, molecular mechanisms and phenotypes related to OA pathogenesis.
The translational potential of this article: The search for new therapeutic targets to treat people suffering from OA remains urgent as there is currently no disease-modifyingtherapy available for this disease. This review discusses how GLP-1 analogues could be potential DMOADs for treating OA thanks to their anti-inflammatory, immunoregulatory and differentiation properties.
Keywords: Cartilage; Glucagon-like peptide-1 (GLP-1); Glucagon-like peptide-1 receptor (GLP-1R); Liraglutide; Osteoarthritis; Synovial tissue.
Click to expand...
THey said the same thing about statins 20 years ago.
 
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