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What's your limit on steroid mg per year?

Discussion in 'Pain Medicine' started by lobelsteve, Jun 19, 2008.

  1. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor Classifieds Approved 10+ Year Member

    May 30, 2005
    Canton GA
    I try and keep things under 320mg equivalents total for all injections.
    I have been in clinics that use 450mg, others with no limit ($$).

    Where is the data?

    Using 6-12mg Celestone I can get 4-8 total injections for a patient in a year to cover knees, shoulders, spine, etc.
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  3. pmrmd

    pmrmd SDN Lifetime Donor Lifetime Donor Classifieds Approved 7+ Year Member

    Mar 22, 2008
    Phoenix, Arizona
    its been awhile since i looked at the actual article, but the tenet of three shots in a year was based on an editorial from some british orthopod back in the late 50s or 60s. there is no science to it whatsoever. i will get the exact article for you. its here somewhere.

    also from the 1960s, journal of rheumatology: the depo preparations, that is steroid + acetate cause a sub-clinical inflammatory process, with PMNs, and it was postulated that PMNs cause cartilage destruction with enzyme release to clear the foreign body crystal. non-particulate steroid causes no such reaction, but obviously is shorter acting.

    i only use decadron for all my injections and it works quite well and is extremely safe without sequellae as long as there is a sufficient wash-out period, about 3 days. its half-life is 5 hrs.

    my $.02
  4. Tenesma

    Tenesma Senior Member 10+ Year Member

    Jun 11, 2002
    a lot of my rheumatologist friends will do 80mg of depomedrol into joints every 2months... and will occasionally do more if there is a bad flare up...

    i figure that for them that isn't much of a big deal since they maintain a lot of their patients on all kinds of crazy immunosuppressants...

    of course, i find that excessive and my mantra is no more than 320mg/year if you are over 65 and no more than 240mg/year if you are under 65 and no more than 80mg/year if you are under 35... totally without any scientific validity - but it helps limit young people from being over injected... my primary fear is that 30 years from now one patient develops an osteoporotic compression fracture and blames it on too many steroid injections...
  5. NOSfan

    NOSfan 10+ Year Member

    Aug 15, 2007
    Taken from:

    Pain Physician, Volume 5, Number 2, pp 182-199

    2002, American Society of Interventional Pain Physicians®
    ISSN 1533-3159
    Review Article
    Role of Neuraxial Steroids in Interventional Pain Management
    Laxmaiah Manchikanti, MD

    Frequency and total number of injections are key issues,
    although controversial and poorly addressed. Some authors
    recommend one injection for diagnostic as well as
    therapeutic purposes; others preach three injections in a
    series irrespective of patient’s progress or lack thereof; still
    others suggest three injections followed by a repeat course
    of three injections after 3; 6; or 12- month intervals; whereas
    others propose an unlimited number of injections with no
    established goals or parameters. A limitation of 3 mg/kg
    of body weight of steroid or 210 mg/year in an average
    person and a lifetime dose of 420 mg of steroid also has
    been advocated.

  6. SSdoc33

    SSdoc33 10+ Year Member

    Apr 23, 2007

    well..... i guess that just answers all of the questions......
  7. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    There is no literature to say what dose is standard per injection.

    There is no literature to say what a time-dependent dose limit should be.

    There is no literature to say what a lifetime dose should be.

    There are only opinions without any science to back them up.

    Rheumatologists and pulmonologists give people 1000's of mg/year orally. They get cushingoid and dependent on the steroids, as well as osteoporotic, insomniac, get stomach ulcers, easy bruising and many other side effects, but no one says there's a lifetime limit or yearly limit.

    Who's gonna do the study of how much is too much, except retrospective chart reviews?

    Use as little as you can, as infrequently as you can, repeating as few times as possible.

    Anyone here include cumulative steroid side effects in their written consents?
  8. Mister Mxyzptlk

    Mister Mxyzptlk 10+ Year Member

    May 16, 2006
    Yewston, TX
    In terms of HPA suppression the vast majority of people have recovered within 3 months after a weekly "series of 3" with triamcinolone. I (arbitrarily) try to give my patients a "rest" for 6 months after successive exposures over a short time.

    The use of midazolam sedation appears to prolong the effect.

    I am unaware of any literature that gives a time frame for developing side effects due to steroid exposure.

    Since even at 6 weeks there is still significant suppression, the timing of steroid exposure before scheduled major surgery is a factor. I haven't heard of people going into Addisonian crisis because of having surgery after an ESI, but maybe we should advise our patients to tell their surgeon.
  9. nvrsumr

    nvrsumr Member 10+ Year Member

    Apr 25, 2002
    Copied this from a post of mine in an earlier discussion.

    The only article Ive ever been able to find regarding coritisol levels after ESI is: Burn et al., Duration of action of methyl prednisolone A study of patients with lumbosciatic syndrome. American Journal of Physical Medicine. 53:1, 1974

    Anyway 72 patients received epidural injection including either 80mg or 160mg methyl prednisolone (plus a little hydrocortisone thrown in for good measure). Cortisol levels almost normal by week 2 and normal by week 3.
  10. Mister Mxyzptlk

    Mister Mxyzptlk 10+ Year Member

    May 16, 2006
    Yewston, TX
    Kay J, Findling JW, Raff H. Epidural triamcinolone suppresses the pituitary-adrenal axis in human subjects. Anesth Analg. 1994 Sep;79(3):501-5.
  11. nvrsumr

    nvrsumr Member 10+ Year Member

    Apr 25, 2002
    Thanks Gorback-looks like a lot better paper than the 1970s one I have scanned onto a pdf! Unfortunately my pub med subsrciption only lets me go back to 1995 for free so Ill have to rely on the abstract.

    Anesth Analg 1994; 79:501-505
    Epidural Triamcinolone Suppresses the Pituitary-Adrenal Axis in Human Subjects
    Jonathan Kay, MD, James W. Findling, MD, and Hershel Raff, PhD
    Departments of Anesthesiology, Medicine, and Endocrine Research, St. Luke's Medical Center, and the Medical College of Wisconsin, Milwaukee, Wisconsin

    Epidural steroids (ESI) are often used for the treatment of low back pain but their effects on the endocrine system have not been determined. We studied the hypothalamic-pituitary adrenal (HPA) axis in 14 patients by measuring plasma adrenocorticotropin (ACTH) by sensitive two-site immunoradiometric assay and by evaluating the acute Cortisol response to cosyntropin. We also evaluated the additional impact of sedation with midazolam before ESI on the degree of suppression of the HPA axis. Plasma ACTH and Cortisol were significantly suppressed 7 days after the first ESI; the group receiving midazolam was more suppressed. By 14 days after the first ESI (7 days after the second ESI), plasma ACTH was more suppressed in the group receiving midazolam and plasma Cortisol was markedly suppressed in both groups. At 48 days after the first ESI (34 days after the third ESI), plasma ACTH and Cortisol were significantly suppressed only in the group that had received midazolam before each ESI. At 48 days, the plasma Cortisol response to cosyntropin was blunted (<500 nmol/L) in 5 of 14 patients. All patients had a normal Cortisol response to cosyntropin by 3 mo after the last ESI. Weekly ESI over 3 wk caused a dramatic acute and chronic suppression of the HPA axis. Median suppression was less than 1 mo, and all patients had recovered by 3 mo. Sedation with midazolam accentuated the suppression of the HPA axis. Exogenous steroid coverage during this potentially vulnerable period should be considered in patients undergoing major stress especially if the adrenocortical response to ACTH is subnormal.
  12. Tenesma

    Tenesma Senior Member 10+ Year Member

    Jun 11, 2002
    another reason not to use sedation...

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