Giving out injectable steroids like candy

[StevenRF]

I've been doing a preceptorship for 1st years, and I've noticed a trend that my fp doc gives out this magical elixer of 5 parts steroid, 4 parts local anaesthetic, 1 part bicarb. Between 1/3 and 1/2 of his patients are on bimonthly injections in multiple places, some of which have been doing it for 1-2 decades. Now most of his patients are geriatrics, but I was under the impression that steroids should be slightly more reserved. Is this practice normal for joint pain... and damn near any other pain come to think of it ?

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[Faebinder]

I've been doing a preceptorship for 1st years, and I've noticed a trend that my fp doc gives out this magical elixer of 5 parts steroid, 4 parts local anaesthetic, 1 part bicarb. Between 1/3 and 1/2 of his patients are on bimonthly injections in multiple places, some of which have been doing it for 1-2 decades. Now most of his patients are geriatrics, but I was under the impression that steroids should be slightly more reserved. Is this practice normal for joint pain... and damn near any other pain come to think of it ?

Before you jump to conclusions..... think about the patient... what are their options... surgery? Some patients would rather die first and live with pain forever... Others... you can talk them into it.... what kind of patient do you have before you?

Gosh, this one patient with rheumatoid arthritis... knees cant go straight or bend fully (always between 20 degrees to 40 degree bends).... I try to talk her into knee replacements.... soooo useless.. she is scared sh##less.. Would rather live with her dangerous knees... fall and break a hip first... shes on aspirin too.. so her chances of bleeding are bad... You just cant talk sense to some people...

 

[drwatson]

I've been doing a preceptorship for 1st years, and I've noticed a trend that my fp doc gives out this magical elixer of 5 parts steroid, 4 parts local anaesthetic, 1 part bicarb. Between 1/3 and 1/2 of his patients are on bimonthly injections in multiple places, some of which have been doing it for 1-2 decades. Now most of his patients are geriatrics, but I was under the impression that steroids should be slightly more reserved. Is this practice normal for joint pain... and damn near any other pain come to think of it ?

Hello, I apologize if you knew this already but just to clarify...it is important to be careful with steroids. This is especially true for systemic steroids. The side effects (hyperglycemia, depressed immune system, etc) are almost worse than whatever you are treating. Local injectable steroids are a little different. The 4 parts local anesthetic may have epinephrine in it. This helps with local vasoconstriction to stop systemic absorption/degradation of the steroid. The joint capsule also holds the steroid in as well. To be honest, I'm not sure of the (patho)physiology of 2 decades worth of joint administration. Regardless, from a whole body point of view, this is much less taxing than oral/systemic steroids.

Hope that helps.

 

[McDoctor]

I've been doing a preceptorship for 1st years, and I've noticed a trend that my fp doc gives out this magical elixer of 5 parts steroid, 4 parts local anaesthetic, 1 part bicarb. Between 1/3 and 1/2 of his patients are on bimonthly injections in multiple places, some of which have been doing it for 1-2 decades. Now most of his patients are geriatrics, but I was under the impression that steroids should be slightly more reserved. Is this practice normal for joint pain... and damn near any other pain come to think of it ?

I'll assume the doc is injecting directly into the affected joint, since he is using a local anaesthetic. There is evidence that intra-articular steroid injections is superior to placebo for painful flares of osteoarthritis (assuming this is why he is using them). There is no data, however, to suggest just how much should be injected or how often this can be done. I hear my attendings say "no more than 4 in a year" or "no more than 6 in a year", but in reality they are basing this on word of mouth and what they were told by their attending doctors in training. In controlled trials, the duration of benefit was about 1 to 3 weeks.

Personally, I'm a little skeptical of the benefits of steroid injections for osteoarthritis, mostly because I'm not convinced how much of the joint damage in these patients is the result of inflammation. Some inflammation contributes, I'm sure, but most of it is the result of anatomical wear and tear. I'll bet injection of the anaesthetic alone would be just as effective for pain relief. It would be interesting to do a double blinded study comparing intra-articular steroids plus anaethetic versus anaestetic alone for knee OA.

Rheumatoid arthritis, of course, is a different ballgame, and I am not familiar with the usefulness of interventions with these patients since they are usually best managed by a Rheumatologist.

As far as your original question goes, there is no evidence to suggest how much is too much when it comes to intra-articular steroid injections for osteoarthritis (which is probably the most common painful joint condition presenting to primary care in older adults). I guess this is where the art of medicine comes in to play.

I hope this helped.

 

[Faebinder]

I'll assume the doc is injecting directly into the affected joint, since he is using a local anaesthetic. There is evidence that intra-articular steroid injections is superior to placebo for painful flares of osteoarthritis (assuming this is why he is using them). There is no data, however, to suggest just how much should be injected or how often this can be done. I hear my attendings say "no more than 4 in a year" or "no more than 6 in a year", but in reality they are basing this on word of mouth and what they were told by their attending doctors in training. In controlled trials, the duration of benefit was about 1 to 3 weeks.

Personally, I'm a little skeptical of the benefits of steroid injections for osteoarthritis, mostly because I'm not convinced how much of the joint damage in these patients is the result of inflammation. Some inflammation contributes, I'm sure, but most of it is the result of anatomical wear and tear. I'll bet injection of the anaesthetic alone would be just as effective for pain relief. It would be interesting to do a double blinded study comparing intra-articular steroids plus anaethetic versus anaestetic alone for knee OA.

Rheumatoid arthritis, of course, is a different ballgame, and I am not familiar with the usefulness of interventions with these patients since they are usually best managed by a Rheumatologist.

As far as your original question goes, there is no evidence to suggest how much is too much when it comes to intra-articular steroid injections for osteoarthritis (which is probably the most common painful joint condition presenting to primary care in older adults). I guess this is where the art of medicine comes in to play.

I hope this helped.

Back to immunology basic science.... TNF and tearing of tissue results in release of different pain factors... some of which are released by our infamous white cells when they come to break down dead tissue.. releasing more pain transmittors.... The corticosteroids stops the attempt to repair and thus stops the pain... this will happen regardless of what was the cause of the destruction (inflammatory such as RA or non-inflammatory such as OA). Of course with RA you will see better results because the destruction process is slowed or temporary halted by the corticosteroids.

 

[YouDontKnowJack]

Do you offer a patient injections if she can't turn on a faucet due to pain?
you offer alternatives first, right?

 

[McDoctor]

Back to immunology basic science.... TNF and tearing of tissue results in release of different pain factors... some of which are released by our infamous white cells when they come to break down dead tissue.. releasing more pain transmittors.... The corticosteroids stops the attempt to repair and thus stops the pain... this will happen regardless of what was the cause of the destruction (inflammatory such as RA or non-inflammatory such as OA). Of course with RA you will see better results because the destruction process is slowed or temporary halted by the corticosteroids.

I still think the mechanism you are describing is not the principle cause of pain in osteoarthritis. Most patients with OA describe pain with activity that is improved with rest. They rarely have nocturnal symptoms, so much so that the presence of such is classically considered a "red flag" that there is a seperate acute process going on. (I realize I wrote the "joint damage" is not primarily due to inflammation. I meant to say "joint pain" as not due to inflammation in my prior post.)

Thus, I'd argue the pain is primarily the result of anatomic distortions within the joint, and that the role of inflammation for causing pain is minor. Otherwise, one would expect the pain to be more profound at rest and less influenced by activity. Also, one would expect NSAIDS to be far superior to Acetominophen if OA where primarily an inflammatory process. But studies show NSAIDS are only modestly better, and most experts contend acetominophen should be first line therapy.

I don't disagree that some joint remodeling occurs, and this occurs via an inflammatory process, I just think that the role of this inflammation in causing pain is very minor. Also, this inflammatory remodeling process probably is not continuous, but rather it occurs in phases. (There is plenty of evidence to support this claim). I suppose one could make the argument that we should then inject steroids during painful "flares" (assuming others causes have been ruled out), in order to have a disease modifying effect. But I'm not sure how reliably a Family Physician (myself included) can clinically detect these inflammatory "flares" based on findings in the office.

I think the results we see in our patients with these injections would be less dramatic if we did not mix the steroid with anaesthetics. As far as what the clinical implications would be for twice monthly injections, as per the question posed by the OP, I think they are mostly unknown. But keep in mind anytime you enter a joint with a needle, you are potentially introducing infection. And routine twice monthly intra-articular injections, in the same patient, definitely exceeds what most would consider usual practice among FP's and Rheumatologists.

 

[Faebinder]

I still think the mechanism you are describing is not the principle cause of pain in osteoarthritis. Most patients with OA describe pain with activity that is improved with rest. They rarely have nocturnal symptoms, so much so that the presence of such is classically considered a "red flag" that there is a seperate acute process going on. (I realize I wrote the "joint damage" is not primarily due to inflammation. I meant to say "joint pain" as not due to inflammation in my prior post.)

Thus, I'd argue the pain is primarily the result of anatomic distortions within the joint, and that the role of inflammation for causing pain is minor. Otherwise, one would expect the pain to be more profound at rest and less influenced by activity. Also, one would expect NSAIDS to be far superior to Acetominophen if OA where primarily an inflammatory process. But studies show NSAIDS are only modestly better, and most experts contend acetominophen should be first line therapy.

I don't disagree that some joint remodeling occurs, and this occurs via an inflammatory process, I just think that the role of this inflammation in causing pain is very minor. Also, this inflammatory remodeling process probably is not continuous, but rather it occurs in phases. (There is plenty of evidence to support this claim). I suppose one could make the argument that we should then inject steroids during painful "flares" (assuming others causes have been ruled out), in order to have a disease modifying effect. But I'm not sure how reliably a Family Physician (myself included) can clinically detect these inflammatory "flares" based on findings in the office.

I think the results we see in our patients with these injections would be less dramatic if we did not mix the steroid with anaesthetics. As far as what the clinical implications would be for twice monthly injections, as per the question posed by the OP, I think they are mostly unknown. But keep in mind anytime you enter a joint with a needle, you are potentially introducing infection. And routine twice monthly intra-articular injections, in the same patient, definitely exceeds what most would consider usual practice among FP's and Rheumatologists.

Agreed with everything you said.

 

[deleted87716]

Bimonthly injections implies that a shot offers relief for less than two weeks. That sounds like treatment failure to me.

 

[StevenRF]

Whoops, I meant every other month...6 to 10 weeks usually... But yea he injects it right into the joint. The patients rave about how well it works though. Kinda scary on the fat ones though. On this one lady he used the longest needle I've ever seen to get through this lady's ass to reach her lumbar sacral region.

Guess it's ok then. It just seemed slightly sketch since it was similar to what my father was given back in the 70's during college football, but that stuff was all under the table hush hush. But then again since most college players are runnin on dianabol, I guess local steroids won't make much of a difference.