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Lee D, Carrera EJ, Hagens R, Yeung G, Garvan CW, Rothman MS, Akuthota V. Serum cortisol level to screen for significant hypothalamic-pituitary-adrenal axis suppression in patients receiving multiple steroid injections. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:97-103. [PMID: 37819765 DOI: 10.1093/pm/pnad138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 09/02/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Morning serum cortisol level (mSCL) is a practical screening tool for hypothalamic-pituitary-adrenal (HPA) axis suppression and has been used to assess for duration of cortisol deficiency after epidural and peripheral glucocorticoid injections. More evidence is needed to establish the utility of mSCL in patients undergoing repeat injections with increasing cumulative glucocorticoid equivalent dose (CGED) that could place them at higher risk of HPA axis suppression. OBJECTIVES To estimate the prevalence of spine injection candidates with significant HPA axis suppression (sigAS), to understand the correlation between 12 months of CGED and the presence of sigAS based on the timing of mSCL collection after the most recent glucocorticoid injection (within 6 weeks or between 6 weeks and 12 months), and to investigate demographic and clinical factors relating to sigAS. METHODS Retrospective chart review of patients scheduled for spine injection who had an associated mSCL and documented histories of prior glucocorticoid injections. The steroid name, dose, type, and procedure location were recorded for each injection that occurred within 12 months before mSCL. CGED was calculated from standard glucocorticoid equivalent conversion factors. RESULTS SigAS was present in 7.8% to 22% of the analysis cohorts. There was no association found between CGED and sigAS regardless of timing of mSCL. There was a trend toward lower mSCL and sigAS with increasing CGED. There were no significant relationships found between sigAS and overall demographic or clinical factors. CONCLUSIONS A 3-fold reduction in the rate of sigAS was noted 6 weeks after the most recent steroid injection. Using mSCL provides a template to investigate the impact of CGED and the best timing for mSCL collection in order to define a more practical guideline to identify patients at higher risk of sigAS earlier and plan for future spine injections.
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Affiliation(s)
- Debbie Lee
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Eduardo J Carrera
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Ryan Hagens
- Department of Physical Medicine and Rehabilitation, UCLA David Geffen School of Medicine/UCLA Medical Center/VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Gerald Yeung
- Department of Orthopedics Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA 94063, United States
| | - Cynthia W Garvan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, United States
| | - Micol S Rothman
- Department of Medicine-Endocrinology/Metabolism/Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Venu Akuthota
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States
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Clare S, Dash A, Liu Y, Harrison J, Vlastaris K, Waldman S, Griffin R, Cooke P, Vad V, Casey E, Bockman RS, Lane J, McMahon D, Stein EM. Epidural Steroid Injections Acutely Suppress Bone Formation Markers in Postmenopausal Women. J Clin Endocrinol Metab 2022; 107:e3281-e3287. [PMID: 35524754 DOI: 10.1210/clinem/dgac287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Over 9 million epidural steroid injections (ESIs) are performed annually in the United States. Although these injections effectively treat lumbar radicular pain, they may have adverse consequences, including bone loss. OBJECTIVE To investigate acute changes in bone turnover following ESI. We focused on postmenopausal women, who may be at greatest risk for adverse skeletal consequences due to the combined effects of ESIs with aging and estrogen deficiency. METHODS Single-center prospective observational study. Postmenopausal women undergoing lumbar ESIs and controls with no steroid exposure were included. Outcomes were serum cortisol, markers of bone formation, osteocalcin, and procollagen type-1 N-terminal propeptide (P1NP), and bone resorption by C-telopeptide (CTX) measured at baseline, 1, 4, 12, 26, and 52 weeks after ESIs. RESULTS Among ESI-treated women, serum cortisol declined by ~50% 1 week after injection. Bone formation markers significantly decreased 1 week following ESIs: osteocalcin by 21% and P1NP by 22%. Both markers remained suppressed at 4 and 12 weeks, but returned to baseline levels by 26 weeks. There was no significant change in bone resorption measured by CTX. Among controls, there were no significant changes in cortisol or bone turnover markers. CONCLUSION These results provide evidence of an early and substantial reduction in bone formation markers following ESIs. This effect persisted for over 12 weeks, suggesting that ESIs may have lasting skeletal consequences. Given the large population of older adults who receive ESIs, further investigation into the long-term skeletal sequelae of these injections is warranted.
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Affiliation(s)
- Shannon Clare
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Alexander Dash
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Yi Liu
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Jonathan Harrison
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Katelyn Vlastaris
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Seth Waldman
- Department of Anesthesiology, Critical Care, & Pain Management, Hospital for Special Surgery, and Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Robert Griffin
- Department of Anesthesiology, Critical Care, & Pain Management, Hospital for Special Surgery, and Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Paul Cooke
- Department of Physiatry, Hospital for Special Surgery, New York, NY 10021, USA
| | - Vijay Vad
- Department of Physiatry, Hospital for Special Surgery, New York, NY 10021, USA
| | - Ellen Casey
- Department of Physiatry, Hospital for Special Surgery, New York, NY 10021, USA
| | - Richard S Bockman
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Joseph Lane
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Donald McMahon
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Emily M Stein
- Endocrinology Division, Hospital for Special Surgery, New York, NY 10021, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
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Krez A, Liu Y, Kanbour S, Clare S, Waldman S, Stein EM. The skeletal consequences of epidural steroid injections: a literature review. Osteoporos Int 2021; 32:2155-2162. [PMID: 34089066 DOI: 10.1007/s00198-021-05986-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022]
Abstract
UNLABELLED This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs. PURPOSE Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids. METHODS Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed. RESULTS Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes. CONCLUSIONS While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment.
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Affiliation(s)
- A Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Y Liu
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Kanbour
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Clare
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Waldman
- Department of Anesthesiology, Critical Care, & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - E M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Shin WS, Ahn DK, Kim MJ, Cho KJ, Go YR. Influence of Epidural Steroid Injection on Adrenal Function. Clin Orthop Surg 2019; 11:183-186. [PMID: 31156770 PMCID: PMC6526135 DOI: 10.4055/cios.2019.11.2.183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 11/06/2022] Open
Abstract
Background Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients. Methods This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7-28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test. Results There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015). Conclusions Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.
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Affiliation(s)
- Won Shik Shin
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Dong Ki Ahn
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Myung Jin Kim
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Kyung Jun Cho
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Young Rok Go
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
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Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM R 2019; 11:409-419. [PMID: 30925034 DOI: 10.1002/pmrj.12042] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022]
Abstract
Local glucocorticoid injections are often used to treat joint, soft tissue, or spinal pain, but the systemic side effects associated with these injections are poorly understood and not well recognized. There are significant known risks to systemic administration of glucocorticoids. However, there are no guidelines that address issues of systemic absorption, overall systemic risks, or other side effects of locally injected glucocorticoids. For this review, a literature search was performed, and the available evidence on systemic absorption and clinical side effects of intra-articular and epidural glucocorticoids was synthesized. The goal was to improve clinical understanding of risks associated with these injections. Existing data suggest there is significant individual variability in the amount of systemic absorption and clinical effects of locally injected glucocorticoids. However, it is clear that both intra-articular and epidural injections can have systemic effects for weeks and that complications may be associated with their use, including Cushing syndrome, loss of bone density, infection, and hyperglycemia. The concurrent use of oral steroids, the number of injections, and the type and dose of glucocorticoids used all are important considerations in estimating risks. The total dose calculation of cumulative glucocorticoid exposure should include all local injections. Caution should be exercised when local glucocorticoid injections are used in higher risk patients, such as postmenopausal women, people with diabetes, and those considering surgery in the near term. Better provider awareness of possible systemic risks should improve decision making and informed consent with patients when considering intra-articular and epidural steroid injections for painful conditions. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Alison Stout
- Evergreen Healthcare, 12039 NE 128th St Suite 500, Kirkland, WA 98034
| | - Janna Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Christopher J Standaert
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA
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6
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Affram KO, Reddy TL, Osei KM. A Rare Case of Thyrotoxic Periodic Paralysis After Epidural Steroid Injection: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1453-1458. [PMID: 30531678 PMCID: PMC6293861 DOI: 10.12659/ajcr.911270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 36 Final Diagnosis: Epidural steroid induced thyrotoxic periodic paralysis Symptoms: Paralysis Medication: — Clinical Procedure: Epidural steroid injection Specialty: Endorinology and Metabolic
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Affiliation(s)
- Kwame Ofori Affram
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Tanya Luke Reddy
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Kofi M Osei
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
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Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, van Kleef M, Rathmell JP, Van Zundert J. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. Pain Pract 2018; 19:61-92. [PMID: 29756333 PMCID: PMC7379698 DOI: 10.1111/papr.12709] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review. METHODS A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. RESULTS Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected. CONCLUSION Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Jasper de Jong
- Department of Pain Management, Westfriesgasthuis, Hoorn, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - James P Rathmell
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium.,Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
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9
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Iranmanesh A, Gullapalli D, Singh R, Veldhuis JD. Hypothalamo-pituitary-adrenal axis after a single epidural triamcinolone injection. Endocrine 2017; 57:308-313. [PMID: 28674775 PMCID: PMC5554884 DOI: 10.1007/s12020-017-1357-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/14/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE To quantify adrenocorticotropin and cortisol secretion after epidural glucocorticoid injection. METHODS Eight men (ages 25-63 year) were studied at baseline, 1, 4, and 12 weeks after triamcinolone (80 mg) injection epidurally. Adrenocorticotropin (pg/mL) and cortisol (µg/dL) were measured every 10 min for 4 h, and after Corticotropin-releasing hormone (CRH) (1 µg/kg) injection. RESULTS Epidural triamcinolone markedly suppressed: (1) pre-CRH injection ACTH (from 18 ± 3.1 to 4.8 ± 0.4: P < 0.01) and cortisol (from 12.2 ± 1.6 to 1.6 ± 0.3: P < 0.0001) at week 1, with recovery at 4 weeks, and (2) CRH-stimulated 3-h summed ACTH (from 633 ± 116 to 129 ± 10 pg/mL, P < 0.0001), and 3-h summed cortisol at week 1 (from 385 ± 29 to 56 ± 22 µg/dL, P < 0.0001) and 4 weeks (284 ± 53; P < 0.01). Serum cortisol was <18 µg/dL in eight of eight men at 4 weeks, and six of eight men at week 12. Urinary-free cortisol (µg/24 h) remained low at week 12: baseline (60 ± 6.5); week 1 (9.0 ± 1.3, P < 0.01); week 4 (36 ± 8.6) and week 12 (38 ± 4.1). Urinary cortisol/cortisone ratios rose at week 4 only. Serum triamcinolone peaked at week 1 (16/16 samples), declining at week 4 (13/16 samples) and week 12 (6/16 samples). LIMITATIONS Relatively small group. CONCLUSION Epidural triamcinolone suppresses unstimulated and CRH-stimulated ACTH and cortisol secretion for 1-4 weeks but urinary free cortisol ≥12 weeks. Suppression of ACTH and cortisol after glucocorticoid treatment is thus complex.
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Affiliation(s)
- Ali Iranmanesh
- Endocrine and Neurology Sections, Medical Service, Salem Veterans Affairs Medical Center, Salem, VA, 24153, USA
| | - Dakshinamurty Gullapalli
- Endocrine and Neurology Sections, Medical Service, Salem Veterans Affairs Medical Center, Salem, VA, 24153, USA
| | - Ravinder Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Johannes D Veldhuis
- Department of Medicine, Endocrine Research Unit, Mayo School of Graduate Medical Education, Clinical Translational Science Center, Mayo Clinic, Rochester, MN, 55905, USA.
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Goel AP, Nguyen VH, Hamill-Ruth R. Use of a Risk-Stratification Tool in Identification of Potential Adrenal Suppression Preceding Steroid Injection Therapy in Chronic Pain Patients. PAIN MEDICINE 2015; 16:2226-34. [PMID: 26243057 DOI: 10.1111/pme.12855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who present for steroid injections are not routinely screened for potential hypothalamic-pituitary-adrenal (HPA) axis suppression from previous steroid exposure. Patients often receive various steroid therapies that are not reported by the patient or recorded in available medical records. Yet, HPA axis suppression has been reported with a single intra-articular injection. METHODS An IRB-approved quality improvement questionnaire was implemented to comprehensively screen patients for risk of HPA axis suppression secondary to prior and/or concurrent corticosteroid use. This questionnaire was given to adult patients seen in a University Pain Management Clinic, who were being considered for a steroid injection, to define the extent of exposure to corticosteroids either by mouth, topically, inhaled, or systemic/local injection within the past 6 months. RESULTS Two hundred patients completed the questionnaire. Eighty-nine patients (44.5%) screened positive for significant steroid exposure with a screen score of three or above. The average score for the screen positive group was 6.31 ± 3.47 (range 3-22). Women were 1.9 times more likely to screen positive than men (53.4% vs 27.5%, P < 0.0004). Otherwise, the screen positive and screen negative groups were similar in demographic characteristics (age, BMI, and diabetes status). CONCLUSIONS Our results suggest that patients receive steroids from many sources and may be at risk for HPA axis suppression. Further testing is necessary to determine if these patients indeed have biochemical evidence of adrenal suppression. Utilization of a screening questionnaire might help identify patients who should be considered for HPA axis testing prior to steroid injections.
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Affiliation(s)
| | | | - Robin Hamill-Ruth
- Department of Anesthesiology, Division of Pain Medicine, University of Virginia Health System, Charlottesville, Virginia
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11
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Johnston PC, Lansang MC, Chatterjee S, Kennedy L. Intra-articular glucocorticoid injections and their effect on hypothalamic-pituitary-adrenal (HPA)-axis function. Endocrine 2015; 48:410-6. [PMID: 25182149 DOI: 10.1007/s12020-014-0409-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/26/2014] [Indexed: 12/27/2022]
Abstract
The use of intra-articular (IA) glucocorticoids for reducing pain and inflammation in patients with osteoarthritis, rheumatoid arthritis, and other inflammatory arthropathies is widespread among primary care physicians, specialists, and non-specialists in the United States. Injectable glucocorticoids have anti-inflammatory and analgesic properties which can be effective in improving clinical parameters such as pain, range of motion, and quality of life. After injection into the IA space, glucocorticoids may be systemically absorbed; the degree of absorption can depend on the size of the joint injected, the injectable glucocorticoid preparation used, the dosage, and the frequency of the injection. The adverse effects of intra-articular glucocorticoid injections (IAGC) can often be overlooked by both the patient and physicians who administer them, in particular the potential deleterious effect on the hypothalamic-pituitary-adrenal (HPA)-axis which can result in adrenal suppression and/or iatrogenic Cushing syndrome. In this paper we provide an overview on the often under-recognized effects of IAGC on HPA-axis function.
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Affiliation(s)
- Philip C Johnston
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA,
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Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015; 5:129-46. [DOI: 10.2217/pmt.14.53] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
SUMMARY Epidural steroid injections (ESIs), which can provide significant but temporary pain relief in well-selected patients, are the most commonly performed procedure in pain management. The anatomy of the epidural space provides a framework for understanding risks associated with ESIs, a topic relevant to both patients and physicians in interventional pain, surgery and primary care. Safety considerations of epidural steroids include drug preparation and myriad physiological effects stemming from steroid exposure. Although major complications associated with ESI occur rarely, potentially catastrophic events resulting from infectious, hematologic and neurologic morbidity may lead to permanent injury. The safety profile of ESIs may improve with development and dissemination of sound injection technique, safer compounds manufactured in a sterile manner and deficient of thromboembolic potential and the application of existing technology.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology, Critical Care & Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - David Chang
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
| | - Steven P Cohen
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Pain Treatment Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, 707 North Broadway, Baltimore, MD 21205, USA
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Hypothalamic-Pituitary-Adrenal Suppression and Iatrogenic Cushing's Syndrome as a Complication of Epidural Steroid Injections. Case Rep Endocrinol 2013; 2013:617042. [PMID: 23991341 PMCID: PMC3749537 DOI: 10.1155/2013/617042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 07/10/2013] [Indexed: 11/18/2022] Open
Abstract
Epidural steroid injections are well accepted as a treatment for radicular back pain in appropriate candidates. While overall incidence of systemic side effects has not been well established, at least five biochemically proven cases of iatrogenic Cushing's Syndrome have been reported as complications of epidural steroid treatment. We present an additional case of iatrogenic Cushing's Syndrome and adrenal suppression in a middle-aged woman who received three epidural steroid injections over a four-month period. We review this case in the context of previous cases and discuss diagnostic and management issues.
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Dort K, Padia S, Wispelwey B, Moore CC. Adrenal suppression due to an interaction between ritonavir and injected triamcinolone: a case report. AIDS Res Ther 2009; 6:10. [PMID: 19505306 PMCID: PMC2701432 DOI: 10.1186/1742-6405-6-10] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 06/08/2009] [Indexed: 11/29/2022] Open
Abstract
Two HIV-1 infected patients developed signs and symptoms consistent with adrenal suppression after being exposed to intra-articular triamcinolone acetate while also receiving ritonavir as part of their highly active antiretroviral therapy. Laboratory evaluation confirmed secondary adrenal suppression in both cases. Both patients recovered without the need for chronic replacement steroids. Adrenal suppression has been described as an adverse outcome in patients treated with fluticasone and concomitant ritonavir. In the reported cases, the adrenal suppression likely developed as a result of increased systemic concentrations of triamcinolone due to an inhibition of cytochrome p450 3A4 metabolism. Practitioners of HIV medicine should be aware of the potential negative interaction of injected triamcinolone and ritonavir.
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Ramanathan R, Pau AK, Busse KH, Zemskova M, Nieman L, Kwan R, Hammer JH, Mican JM, Maldarelli F. Iatrogenic Cushing syndrome after epidural triamcinolone injections in an HIV type 1-infected patient receiving therapy with ritonavir-lopinavir. Clin Infect Dis 2008; 47:e97-9. [PMID: 18991509 DOI: 10.1086/593314] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the first case of a human immunodeficiency virus type 1 (HIV-1)-infected individual receiving combination antiretroviral therapy, which included ritonavir, who developed Cushing syndrome with profound complications after epidural triamcinolone injections. This case highlights the potential of ritonavir interactions even with local injections of a corticosteroid.
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Affiliation(s)
- Roshan Ramanathan
- Clinical Parasitology Unit and Helminth Immunology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Heran MKS, Smith AD, Legiehn GM. Spinal injection procedures: a review of concepts, controversies, and complications. Radiol Clin North Am 2008; 46:487-514, v-vi. [PMID: 18707959 DOI: 10.1016/j.rcl.2008.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.
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Affiliation(s)
- Manraj K S Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, Canada.
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