The systemic effects of intra-articular steroid injections- should CIVID-19 change our practice?

ABSTRACT

Aim: The COVID-19 pandemic prompted us to review and often suspend services, while patients continue to suffer with painful musculoskeletal conditions. The diagnostic and therapeutic value of intraarticular corticosteroid injections (IACSI) cannot be denied. Current BOA guidelines advise giving the lowest effective dose for inflammatory arthritis and limit use in osteoarthritis to patients with high levels of pain and disability. We aimed to evaluate the literature pertaining to the use of IACSI and the potential systemic immunosuppressive effects. Method: We searched Medline, using the terms 'systemic effects of intra- articular steroid' and 'clinical course of Coronavirus infection in patients with steroid use', between 1997 and 2020. Results: No studies specifically looked at the systemic effects of intraarticular steroids in the presence of COVID-19 infection;however, four studies were identified which concluded that intra-articular steroid injections resulted in sufficient systemic absorption to cause suppression of the hypothalamic-pituitary-adrenal axis and endogenous cortisol production. These effects are dose dependent and are more common in patients with inflammatory joint diseases. A further four RCT's, including one systematic review, showed that suppressed cortisol concentration was associated with a significant increase in mortality. Conclusions: There is a lack of evidence in relation to the use of intraarticular steroids in COVID-19. However, evidence suggests that intraarticular steroids can result in systemic absorption and suppression of endogenous cortisol production thus increasing the potential risk of complications of COVID-19. We therefore support cautious use of low dose steroid injections in patients with inflammatory arthritis, where no alternative treatment is available.