Impact of Variation of Corticosteroid Dose, Injection Site, and Multiple Injections on Blood Glucose Measurement in Diabetic Patients

Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities

Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.

Impact of Intra-Articular Corticosteroid Injection on Glycemic Control: A Population-Based Cohort Study

This retrospective cohort study investigated the longer-term hyperglycemic effects of intra-articular corticosteroid (IACS) administration by evaluating changes in A1C after large joint IACS injection. Among 1,169 patients (mean age 66.1 ± 12.2 years, 52.8% female), 184 (15.7%) experienced a greater-than-expected rise in A1C (actual A1C ≥0.5% above predicted) after IACS. Greater-than-expected rise in A1C was associated solely with baseline A1C (odds ratio [OR] 1.84, 95% CI 1.08-3.13 for baseline A1C of 7.0-8.0% compared with <7.0% and OR 4.79, 95% CI 2.83-8.14 for baseline A1C >8.0% compared with <7.0%). Although most patients do not experience an increase in A1C after IACS, clinicians should counsel patients with suboptimally controlled diabetes about risks of further hyperglycemia after IACS administration.

Musculoskeletal corticosteroid injections: Recommendations of the French Society for Rheumatology (SFR)

Musculoskeletal corticosteroid injections are widely performed, although the exact practice varies greatly due to advances in knowledge and techniques. This justifies updating and drawing up good practice recommendations. Using a consensus model formalized by the French National Authority for Health (HAS) and based on a literature review that resulted in a "white book", 13 recommendations were developed by a group of experts. These recommendations were then sent online to 48 specialists for evaluation, 27 of whom were rheumatologists and 15 of whom were general practitioners. These recommendations were also presented at the 34th annual meeting of the French Society for Rheumatology (SFR) (Paris, December 2021) at a symposium attended by a hundred or so rheumatologists, who voted on these recommendations in person. The results are presented as an overall score out of 10, a median out of 10 and as tertiles. The agreement was excellent for 10 of these 13 recommendations, with mean values of 8.5 to 9.1 out of 10, median values of 9 or 10 out of 10 and agreement of 91.7% to 97.9%, which corresponds to a consensus. The 3 other recommendations were broadly supported but were the subject of more debate. One relates to patient information (mean 7.3/10, median 8/10, upper tertile 72.9%) with discussion about the waiting period. Another related to the summary report (mean 8.4/10, median 9, upper tertile 91.7%) with discussions about its content and the need to specify the lot number of the injected product. The last one related to periprosthetic injections and the need to consult and get approval from a specialist (mean 8.0/10, median 8, upper tertile 83.3%) with mostly the general practitioners having reservations. In all, there is a very strong consensus among the musculoskeletal corticosteroid injection experts and specialists consulted, which justifies them being taken into consideration to improve our daily practice.

The effect of steroid injection into the shoulder on glycemia in patients with type 2 diabetes

Background

Injections of corticosteroids into or around joints have been reported to increase blood glucose in patients with diabetes due to corticosteroid absorption into the bloodstream. However, the magnitude, duration, and clinical implications of local corticosteroid injections on glycemic control are not clear. The purpose of this study was to evaluate the effects of corticosteroid injection to the shoulder on glycemia in patients with type 2 diabetes mellitus using a continuous glucose monitoring device.

Methods

Twenty-five patients with symptomatic shoulder problems and type 2 diabetes mellitus, not treated with insulin, prescribed a corticosteroid injection into the shoulder, were investigated. The patients were connected to a flash glucose monitoring system, which continuously monitored interstitial glucose levels. Data were collected 3 days before injection and for additional 11 days after corticosteroid injection. We analyzed glucose levels in the first 3 days (early postinjection) and on days 4-11 (late postinjection) after the injection and compared them to the preinjection period. The outcome measures included change in the average glucose levels, per patient, between the preinjection and postinjection periods and the differences in the time spent at glucose >180 mg/dL, >250 mg/dL, and >350 mg/dL, per patient, between the preinjection and postinjection periods.

Results

The increase in the mean glucose level per patient was statistically significant from 136 mg/dL in the preinjection period to 159 mg/dL in the first 3 days after the injection and returned to normal thereafter. Time at blood glucose >250 mg/dL increased from 4.3% in the preinjection period to 9.5% on the first day after the injection. It then decreased to 7% on day 2, 3.8% on day 3, and 1.4% in the late postinjection period. New onset of glucose levels >350 mg/dL was found in 4 of 25 patients during the early postinjection period. In all 4 patients, the exposure to severe hyperglycemia (>350 mg/dL) was short. None of the patients required intensification of the antidiabetic treatment or insulin injections.

Conclusion

Local corticosteroid injection to the shoulder can create a significant, short-term increase in systemic glucose levels in patients with D2DM not treated with insulin. Some of these patients may have periods with glucose above 350 mg %. However, these glycemic changes are short lived and are mostly limited to the 2-3 days after the injection. In addition, none of the patients in our study needed any change in antidiabetic treatment or any medical care after the injection.

Serial Intralesional Steroid Injection for Subglottic Stenosis: Systemic Side Effects and Impact on Surgery-Free Interval

Objectives

In-office serial intralesional steroid injections (SILSIs) have become a commonly used treatment for subglottic stenosis. We characterized the impact of SILSIs on the time between operating room visits and incidence of glucocorticoid systemic side effects.

Study Design

Retrospective case series.

Setting

Academic tertiary care center.

Methods

All patients with subglottic stenosis receiving SILSIs at 1 institution from 2016 to 2020 were included. Surgery-free interval was compared using paired t tests. Side effect incidence was calculated with Kaplan-Meier methodology for visualization.

Results

Nineteen patients and 207 procedures were included. The majority of patients were White (95%) and female (95%) and had idiopathic subglottic stenosis (53%). Mean surgery-free interval for all patients was 8.7 months (95% CI, 5.6-11.8) before initiating SILSIs. Of 11 patients with calculable surgery-free interval, 10 experienced improvement, with a mean surgery-free interval increase of 4.6 months (95% CI, 2.4-6.7). Seven patients have not required surgery since initiation of SILSIs, with a mean follow-up time of 28 months (95% CI, 25-31). Noncutaneous systemic side effects occurred at a mean 3.2 months (95% CI, 2.4-4.0) from first injection and included Cushing’s syndrome, increased intraocular pressure, central serous chorioretinopathy, and new insulin requirement in the setting of diabetes.

Conclusions

Ninety-one percent of patients who initiated SILSIs and had a subsequent return to the operating room experienced a mean 4.6-month increase in surgery-free interval. Systemic side effects of glucocorticoids occurred in 32% of patients after initiating SILSIs. This should be considered in preprocedure counseling and side effect monitoring during treatment.

Short course corticosteroid treatment and closed-loop insulin delivery system: the experience of the DBLG1 pre-launch

No abstract (brief report).

EULAR recommendations for intra-articular therapies

OBJECTIVES

To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.

METHODS

A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.

RESULTS

Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.

CONCLUSION

We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.