Steroid injections.. updated Guidance Dec 2020
An update to the clinical guide for the management of patients with musculoskeletal and rheumatic conditions who are already taking corticosteroids, or require initiation of oral/IV corticosteroids, or require a corticosteroid injection in the context of the COVID-19 pandemic has been published on the British Society of Rheumatology website.
The link to the complete update can be found by clicking HERE, however, we have summarised what we believe to be relevant to Primary Care below:
- Don’t abruptly stop current steroids
- Use the lowest possible dose of oral steroids for the shortest period of time
- Think before starting/using steroids in the current pandemic; the benefits must outweigh the risks
- Starting oral prednisolone at more than 5mg per day for more than a month could move an adult into the clinically extremely vulnerable (CEV) group
- Starting oral prednisolone at more than 20mg per day for more than a month will move an adult into the CEV group (NB: this does not apply to children and young people)
- Only give a steroid injection if a patient has significant disease activity and/or intrusive and persisting symptoms, and there are no appropriate alternatives
The effect of intra-articular or intramuscular steroid on the clinical course of COVID-19 is unknown.
Intra-articular, peri-articular and soft tissue injections for MSK pain
Indication e.g. to treat osteoarthritis, shoulder pain, lateral hip pain, carpal tunnel syndrome, trigger digit and de Quervain’s.
Recommend simple analgesia, activity modification, splinting where appropriate and exercise as first line.
Only consider a steroid injection if a patient has failed first line measures, has high levels of pain and disability, and continuation of symptoms will have a significant negative effect on their health and wellbeing.
Patients in the CEV group and steroids: implications
- Starting a course of oral prednisolone lasting more than a month may put someone into the CEV group and their name should be added to the shielding list. The implications of this should be discussed with the patient
- Starting oral prednisolone at more than 20mg per day in an adult for more than a month will move a patient into the CEV group
- A one-off steroid injection for local action will not put someone into the CEV group
- A one-off intramuscular steroid injection will not put someone into the CEV group
Should injected corticosteroids still be used during the COVID-19 pandemic?
As per usual practice, individuals with active infections must not be injected with steroids.
A steroid injection is used in MSK services to control inflammatory joint disease, ease pain, increase mobility and improve quality of life. The duration of effect is variable but it can provide benefit for several months and in certain conditions (such as trigger digit) may provide long-term symptom resolution.
In some patients, the use of an injection can avoid the need for surgery or delay it for a substantial period, thereby reducing the risks of patients undergoing procedures at this time.
However, during the COVID-19 pandemic clinicians need to give extra consideration as to whether the benefits outweigh the risks. The incubation period for coronavirus can be long (up to 14 days) with an estimated median time of 5.1 days.
This means that giving a steroid injection to an asymptomatic patient who is carrying the virus could potentially put them at an increased risk of an adverse outcome from the virus, although it is not known that this is the case, and the level of any increased risk has not been quantified to date.
This potential risk therefore needs particular consideration in more clinically vulnerable patient groups, for example patients over the age of 70, adults belonging to BAME groups, those with diabetes mellitus, chronic respiratory disease and high BMI.
Particularly for patients in the CEV group for COVID-19, the benefits of receiving corticosteroids (orally or parenterally) must outweigh the risks for these patients. The potential risks must be explained to patients to allow an informed, shared decision to be reached regarding whether or not to proceed with steroid injection.
This includes attending a setting where higher levels of COVID-19 may be present, although the clinical area will be set up in a COVID-safe way. Provision of prior information to patients may enable these discussions.