Corticosteroid and Cortisol Serum Levels Following Intra‐articular Triamcinolone Acetonide Lumbar Facet Joint Injections

Dickson, Rozalin R.; Reid, Joel M.; Nicholson, Wayne T.; Lamer, Tim J.; Hooten, W. Michael

doi:10.1111/papr.12686

Cited by 18 publications

(15 citation statements)

References 34 publications

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“…In the review, it is suggested that the effect is maximal after 48 h and lasting for 1–4 weeks. This transient effect of CSI on serum levels is further shown by several studies (Armstrong, English, Gibson, Chakraborty, & Marks, 1981; Derendorf, Möllmann, Grüner, Haack, & Gyselby, 1986; Dickson, Reid, Nicholson, Lamer, & Hooten, 2018; G. Habib, Jabbour, Artul, & Hakim, 2014; Mader, Lavi, & Luboshitzky, 2005; Reeback, Chakraborty, English, Gibson, & Marks, 1980; Weitoft & Rönnblom, 2006). However, the Broerson meta‐analysis did show that there was adrenal insufficiency in patients post CSI (Broersen, Pereira, Jørgensen, & Dekkers, 2015).…”

Section: Introductionsupporting

confidence: 56%

Intra‐articular corticosteroid injections during the COVID‐19 lockdown period: A service evaluation

Newton

Jones²,

Jones

et al. 2020

Musculoskeletal Care

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Section: Introductionsupporting

confidence: 56%

Intra‐articular corticosteroid injections during the COVID‐19 lockdown period: A service evaluation

Newton

Jones²,

Jones

et al. 2020

Musculoskeletal Care

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“…Betamethasone is more soluble than triamcinolone and HPA suppression is seen at doses of 6 mg [ 24 ]. Dickson et al studied facet joint corticosteroid injections with triamcinolone acetonide 40 mg and found that HPA suppression occurs for an average of 4.4 days [ 11 ]. The depressed HPA-axis is of concern in the setting of the COVID-19 pandemic because if a patient were to encounter a stressful event such as a severe infection, s/he may not be able to mount a sufficient stress response to appropriately fight the infection, and a depressed HPA-axis is known to correlate with poor outcomes in critically ill persons [ 8 , 25 , 26 ].…”

Section: Discussionmentioning

confidence: 99%

“…Corticosteroid (betamethasone sodium phosphate and acetate injectable suspension (6 mg/mL, American Regent Inc., Shirley, NY; dose 6–21 mg), triamcinolone acetonide injectable suspension (40 mg/mL, Bristol Myers Squibb Company, New York, NY; dose 40–80 mg), methylprednisolone acetate (40 mg/mL, Pfizer, New York, NY; dose 60 mg), or dexamethasone (4 mg/mL, Fresenius Kabi, Lake Zurich, IL; dose 10 mg) with or without anesthetic (lidocaine 1% (AuroMedics Pharma LLC, E. Windsor, NJ; 1–4 mL) or ropivacaine 0.2% (AuroMedics Pharma LLC, E. Windsor, NJ; 1–5 mL)) or bupivacaine 0.5% (Hospira, Inc, Lake Forest, IL; 2–4 mL) was then injected. Following the injection, the patient was instructed to physically distance for 1–2 weeks, based on the possibility of suppression of the immune system and HPA-axis [ 10 , 11 ].…”

Section: Methodsmentioning

confidence: 99%

Symptomatic COVID-19 infections in outpatient image-guided corticosteroid injection patients during the lockdown phase

et al. 2020

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Background Musculoskeletal pain is a debilitating problem treated with image-guided corticosteroid injections. During the COVID-19 pandemic, multiple societies issued caution statements because of the unknown effect of corticosteroids on the patient's immune system. The purpose is to determine if image-guided corticosteroid injections administered during the COVID-19 lockdown phase were associated with a higher infection rate compared to the general population. Materials and methods In a prospective study, patients undergoing image-guided corticosteroid injections for pain management during the lockdown phase between April 15 and May 22, 2020, were enrolled. One month after the injection, patients were surveyed by telephone for any COVID-19-related symptoms, and the electronic medical record (EMR) was reviewed for symptoms and test results. Results Seventy-one subjects were recruited, 31 (44%) females, 40 (56%) males, ages 58 ± 17 (20-92) years. Follow-up was available in 66 (93%) of subjects, 60 (91%) by phone survey and EMR, 6 (9%) by EMR only, 45 ± 22 (19-83) days after injection. One (1/66, 1.52%; 95% CI 0.04-8.2%) 25-year-old male subject developed symptomatic infection 19 days after a tibiotalar injection. The prevalence of COVID-19 cases in the state of Massachusetts was 0.91% (62,726/6,892,503) during the study period. There was no significant difference in the rate of occurrence of new cases of COVID-19 infection between the corticosteroid injection group and the general population (p = 0.44). Conclusion Image-guided corticosteroid injections for pain management performed during the lockdown phase of the COVID-19 pandemic were not associated with a higher infection rate compared to the general population.

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“…Intra-articular triamcinolone is absorbed into soft tissues over a time course of 2 to 3 weeks. Its effect on adrenal suppression is dose-dependent, with the maximum effect after intra-articular administration observed when levels are greater than 1.9 ng/mL (11). ICS following triamcinolone injections even in the absence of CYP3A4 inhibition has been reported (12).…”

Section: Discussionmentioning

confidence: 99%

Iatrogenic Cushing Syndrome In An Hiv-Infected Patient Secondary to Concomitant Therapy With Genvoya and Epidural Triamcinolone

Mathias

Epstein

2020

AACE Clinical Case Reports

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Objective: We report the first known case of Cushing's syndrome and secondary adrenal insufficiency in a patient with concomitant use of epidural triamcinolone and Genvoya ® (elvitegravir 150mg/cobicistat 150mg/emtricitabine 200mg/tenofovir alafenamide 10mg) for HIV. The prompt recognition of this drug-drug interaction is critical to avoid adverse outcomes when glucocorticoids are used with antiretroviral treatment containing Cobicistat, a potent CYP3A4 inhibitor. Methods: The patient was evaluated by determining morning serum cortisol concentrations, the serum cortisol response to Cosyntropin, and a urine synthetic glucocorticoid panel that is capable of measuring triamcinolone. We also employed the Naranjo Nomogram for Causality as well as a Drug Interaction Probability scale to assess medication-related adverse effects. Long term outcome was assessed by measuring morning serum cortisol and ACTH levels. Results: A 76-year-old female with HIV on Genvoya presented with fatigue, weight loss, and hyperglycemia. She had received multiple epidural triamcinolone injections for chronic back pain before her presentation. We hypothesized that the patient's presentation of Cushing's syndrome and adrenal insufficiency was caused by the inhibition of triamcinolone metabolism by cobicistat. The patient's antiretroviral therapy was changed to a regimen without cobicistat. She was started on maintenance hydrocortisone to prevent an adrenal crisis. A repeat urine glucocorticoid panel, within three days of the patient's HIV regimen being changed, showed a significant decrease in triamcinolone levels. Conclusion: It is essential to avoid drugs that include cobicistat when administering glucocorticoids that are metabolized via the CYP3A4 pathway due to the risk of developing Cushing's syndrome and secondary adrenal insufficiency.

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Corticosteroid and Cortisol Serum Levels Following Intra‐articular Triamcinolone Acetonide Lumbar Facet Joint Injections

Cited by 18 publications

References 34 publications

Intra‐articular corticosteroid injections during the COVID‐19 lockdown period: A service evaluation

Intra‐articular corticosteroid injections during the COVID‐19 lockdown period: A service evaluation

Symptomatic COVID-19 infections in outpatient image-guided corticosteroid injection patients during the lockdown phase

Iatrogenic Cushing Syndrome In An Hiv-Infected Patient Secondary to Concomitant Therapy With Genvoya and Epidural Triamcinolone

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