Comparative assessment of hypothalamic-pituitary-adrenal axis suppression secondary to intrabursal injection of different glucocorticoids: a pilot study

Guaraldi, Federica; Gori, Davide; Calderoni, P; Castiello, Emanuela; Pratelli, Loredana; Leporati, Marta; Arvat, Emanuela; Battaglia, Milva

doi:10.1007/s40618-019-01033-6

Cited by 9 publications

(7 citation statements)

References 19 publications

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“…However, a proportion of injected glucocorticoid reaches the systemic circulation and can affect the HPAA (box 1). Exogenous glucocorticoids can be detected in the urine for months after the injection, pointing to possible prolonged systemic absorption 8485. Repeated injections and higher doses of glucocorticoids increase the risk of GI-AI 8687888990.…”

Section: Factors Affecting Likelihood Of Glucocorticoid Induced Adrenal Insufficiencymentioning

confidence: 99%

Glucocorticoid induced adrenal insufficiency

Prete

Bancos

2021

BMJ

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Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing’s syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.

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Section: Factors Affecting Likelihood Of Glucocorticoid Induced Adrenal Insufficiencymentioning

confidence: 99%

Glucocorticoid induced adrenal insufficiency

Prete

Bancos

2021

BMJ

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“…Unfortunately, the paper did not report standard deviations alongside the 7-day morning serum cortisol values and thus the results were not included in our subsequent meta-analysis. We present the outcome data for this paper alongside the 16 other identified studies [1, 11, 13, 15, 16, 18-22, 26, 27, 32, 36, 56, 59] that were eligible for inclusion in the study (Table 3).…”

Section: Methodsmentioning

confidence: 99%

“…Our review is also limited because of how the results of the primary studies were reported; we were unable to [13] 13 Poor Friedly et al [15] 26 Excellent Dickson et al [11] 17 Fair Guaraldi et al [16] 22 Good Habib et al [18] 12 Poor Habib et al [19] 16 Fair Habib et al [20] 17 Fair Habib et al [21] 18 Fair Habib et al [22] 18 Fair Iranmanesh et al [26] 14 Fair Jacobs et al [27] 9 Poor Maillefert et al [32] 13 Poor Moon et al [36] 17 Fair Tuncer et al [56] 14 Fair Ward et al [59] 15 Fair Weyland et al [60] 8 Poor evaluate whether sex or age was a risk factor for secondary adrenal insufficiency because we did not have access to individual patient data. A previous study of 143 healthy adults [50] demonstrated that both factors determine the secretory profile of cortisol for individuals.…”

Section: Limitationsmentioning

confidence: 99%

“…Unfortunately, the published use of these tests in relation to a corticosteroid injection is inconsistent, with only some authors presenting the results of ACTH stimulation testing [19 ,20, 22, 26, 27]. Instead, many studies [1, 13, 15, 16, 21, 32 ,36, 56] measure morning serum cortisol using a simple blood test to assess peak level of circulating cortisol, from which to draw conclusions about HPA axis function. Although morning serum cortisol does not directly measure HPA axis function, several authors have established thresholds that have high positive and negative predictive values for secondary adrenal insufficiency [30, 35, 53].…”

Section: Introductionmentioning

confidence: 99%

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Are Corticosteroid Injections Associated With Secondary Adrenal Insufficiency in Adults With Musculoskeletal Pain? A Systematic Review and Meta-analysis of Prospective Studies

Whelan

Sim

Smith

et al. 2022

Clin Orthop Relat Res

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Background Corticosteroid injection is a common treatment for individuals experiencing musculoskeletal pain, and it is part of the management of numerous orthopaedic conditions. However, there is concern about offering corticosteroid injections for musculoskeletal pain because of the possibility of secondary adrenal insufficiency. Questions/purposes In this systematic review and metaanalysis of prospective studies, we asked: (1) Are corticosteroid injections associated with secondary adrenal insufficiency as measured by 7-day morning serum cortisol? (2) Does this association differ depending on whether the shot was administered in the spine or the appendicular skeleton? Methods We searched the Allied and Complementary Medicine (AMED), Embase, EmCare, MEDLINE, CINAHL, and Web of Science from inception to January 22, 2021. We retrieved 4303 unique records, of which 17 were eventually included. Study appraisal was via the Downs and Black tool, with an average quality rating of fair. A Grading of Recommendations, Assessment, Development, and Evaluations assessment was conducted with the overall certainty of evidence being low to moderate. Reflecting heterogeneity in the study estimates, a pooled random-effects estimate of cortisol levels 7 days after corticosteroid injection was calculated. Fifteen studies or subgroups (254 participants) provided appropriate estimates for statistical pooling. A total of 106 participants received a spine injection, and 148 participants received an appendicular skeleton injection, including the glenohumeral joint, subacromial bursa, trochanteric bursa, and knee. Results Seven days after corticosteroid injection, the mean morning serum cortisol was 212 nmol/L (95% confidence interval 133 to 290), suggesting that secondary adrenal insufficiency was a possible outcome. There is a difference in the secondary adrenal insufficiency risk depending on whether the injection was in the spine or the appendicular Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

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“…PRP is even better than steroids [12]. Injections with corticosteroid injections are becoming less popular because of potential side (local and systemic) effects [13][14][15][16][17][18][19]. Instead of using steroids, sports doctors are using more and more regional injections with sugar water 5% (S5W) such as dextrose 5% in water (D5W) or glucose 5% in water (G5W) because of easy application and excellent safety profile [20].…”

Section: Treatment Of Hamstring Injurymentioning

confidence: 99%

Hamstring Injury Rehabilitation in the Female Athlete. A Clinical Case

2023

J Ortho Physio

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Hamstring injury is a common sports injury in the female athlete. Both rehabilitation and preventive measures are crucial but not standardized yet. In this article we present a female athlete with a fresh hamstring injury which was treated with both physiotherapeutic treatment as well as with regional sugar water injections into the muscular lesion. The goal of this paper is to share this experience with other physical therapists and sports doctors. This case is also an invitation to the medical community to design randomized trials to confirm our clinical experience with this dual management.

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Comparative assessment of hypothalamic-pituitary-adrenal axis suppression secondary to intrabursal injection of different glucocorticoids: a pilot study

Cited by 9 publications

References 19 publications

Glucocorticoid induced adrenal insufficiency

Glucocorticoid induced adrenal insufficiency

Are Corticosteroid Injections Associated With Secondary Adrenal Insufficiency in Adults With Musculoskeletal Pain? A Systematic Review and Meta-analysis of Prospective Studies

Hamstring Injury Rehabilitation in the Female Athlete. A Clinical Case

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