The Grapevine

Why You Should Avoid Steroids

Arthritis is caused by inflammation of the joints. Particularly, hip and knee joint pain conditions result in osteoarthritis, which also affects the bones. Doctors recommend anti-inflammatory medication, of which steroids are commonly prescribed, either orally, topically or through injections. 

The department of radiology at Boston University School of Medicine had noticed an increasing number of patients whose condition had worsened over time after they received intra-articular corticosteroid (IACS) injections. So much so that they needed hip or joint replacement to solve the incurable pain, which was previously diagnosed as osteoarthritis. 

As previous research had hinted this side effect, they conducted a study of their own to verify and analyze the negative impact of steroid injections in treating pain. Large longitudinal studies are lacking on adverse events associated with steroid injections, hence the researchers undertook this study since the findings were not conclusive. 

“The purpose of this report is to review the existing literature, describe observed adverse joint events after IACS injections, and provide an outlook on how this may affect clinical practice,” the researchers stated in the abstract of their paper published in the journal Radiology on October 15, 2019. The goal was to identify potential risk factors prior to the injection delivered to help endure the pain of osteoarthritic knees and hips, diagnosed at the moderate level of intensity. 

What The Study Found

Boston University is also a city hospital that provides treatment to people with financial difficulties. Certain people with comorbidities cannot handle surgery, hence are referred to the radiology department for IAC injections. Annually, the hospital claims to deliver 500 such injections targeted at the knee and hip joints in the presence of two experienced musculoskeletal radiologists. 

In the year 2018, alone, the hospital recorded one injection each to 459 patients, who were referred by an orthopedic. They came with radiographs to pinpoint the problematic area and a few of them had even undergone a routine MRI. 

Hip replacements Hip related adverse events are more common in patients who take steroids for osteoarthritis. Guilak Laboratory, Washington University

“The IACS injections in hip and knee joints at our institution are composed of 40 mg of triamcinolone, 2 mL of 1% lidocaine, and 2 mL of 0.25% bupivacaine,” the researchers revealed. 

Patients who returned for another consultation because their condition had not improved were put under another round of imaging. They were all patients with a mean age of 57 years old who had taken one to three injections within 2-15 months of the first and second injection given due to the patients following up with the hospital.

“Altogether, based on the available results of postprocedural imaging, we recorded 36 adverse joint events in 36 patients (19 women) out of a total of 459 IACS injections (8%),” the researchers stated in their findings. 

The adverse events related to the joints were of four kinds:

  • Accelerated progression of osteoarthritis in 6 percent of the patients
  • Subchondral insufficiency fracture in less than 1 percent (0.9)
  • Osteonecrosis in less than 1 percent ( 0.7)
  • Rapid Joint Destruction ( 0.7)

After this, one immediate benefit was implemented within the structure of the hospital’s procedures. “When a patient with femoral head osteonecrosis without collapse is referred to our clinic for IACS injection, the potential of accelerating the osteonecrosis leading to joint collapse, the potential for worsened pain, and the need for joint replacement to relieve the pain are now routinely included in the patient’s informed consent at our institution,” the researchers noted. 

“Given that IACS injections are increasingly performed to treat pain in patients with hip or knee OA, we suggest that the radiologic community should actively engage in high-quality research on this topic to better understand potential at-risk conditions prior to intervention and to better understand potential adverse joint events after these procedures to avoid possible complications,” the researchers advised, though more remains to be done.