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.

Rethinking Viscosupplementation: Ultrasound- Versus Landmark-Guided Injection for Knee Osteoarthritis.

OBJECTIVES: Viscosupplementation, intra-articular injection of hyaluronic acid (HA), for knee osteoarthritis has fallen somewhat out of favor, with studies failing to show consistent benefits in pain reduction. Hyaluronic acid must enter the joint space to be beneficial; however, landmark-guided injection can be substantially inaccurate, especially in obese patients. We aimed to determine whether ultrasound (US) guidance to ensure needle placement for HA knee injection resulted in improved outcomes as reflected by surgery-free survival compared to landmark-guided HA knee injection. METHODS: All community-dwelling patients in 6 contiguous surrounding counties receiving HA knee injection either by landmark guidance (n = 647) or by US guidance (n = 500) were analyzed for the degree of arthritis, body mass index, follow-up injection, and subsequent need for knee arthroplasty. A subgroup analysis of obese patients was also performed. RESULTS: The US- and landmark-guided HA injection cohorts were similar with respect to sex, body mass index, and the degree of arthritis. Of 1147 patients receiving knee HA injection, 462 subsequently underwent knee arthroplasty. Significantly fewer patients in the US-guided HA injection cohort went to surgery (33.2%) compared to the landmark-guided cohort (45.8%; P < .001). The subgroup analysis for obese patients showed even larger differences (34.8% versus 51.8%; P < .001). CONCLUSIONS: Knee osteoarthritis treatment by viscosupplementation can be optimized by US guidance, ensuring intra-articular needle placement. Using an objective surgical outcome, our study shows that rethinking viscosupplementation to ensure intra-articular delivery improves effectiveness. Patients receiving US-guided knee HA injection were significantly less likely to undergo subsequent knee arthroplasty than patients receiving landmark-guided HA injection.

Corticosteroid Injections and Risk of Fracture.

Importance: Corticosteroid injections (CSIs) are an important tool for pain relief in many musculoskeletal conditions, but the longitudinal effects of these treatments on bone health and fracture risk are unknown. Objective: To determine whether cumulative doses of corticosteroid injections are associated with higher risk of subsequent osteoporotic and nonosteoporotic fractures. Design, Setting, and Participants: This cohort study included adult patients receiving any CSI from May 1, 2018, through July 1, 2022. Eligible patients resided in Olmsted County, Minnesota, and were empaneled to receive primary care within the Mayo Clinic. Cox proportional hazards regression models were used to evaluate risk of fracture based on cumulative injected corticosteroid dose. Exposure: Receipt of any CSI during the study period. Main Outcomes and Measures: The primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes consisted of risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis. Results: A total of 7197 patients were included in the study (mean [SD] age, 64.4 [14.6] years; 4435 [61.6%] women; 183 [2.5%] Black and 6667 [92.6%] White), and 346 (4.8%) had a new fracture during the study period. Of these fractures, 149 (43.1%) were considered osteoporotic. In the adjusted Cox proportional hazards regression model, there was no association of higher fracture risk based on cumulative CSI dose (adjusted hazard ratio [HR], 1.04 [95% CI, 0.96-1.11]). There was also no associated higher risk of fracture in the non-high-risk (adjusted HR, 1.11 [95% CI, 0.98-1.26]) or osteoporosis (adjusted HR, 1.01 [95% CI, 0.90-1.11]) subgroups. Age, Charleson Comorbidity Index, and previous fracture were the only factors that were associated with higher fracture risk. Conclusions and Relevance: In this cohort study of cumulative injected corticosteroid dose and risk of subsequent fracture, no association was observed, including in patients with a preexisting diagnosis of osteoporosis. Treatment of painful conditions with CSI should not be withheld or delayed owing to concern about fracture risk.

Odds of Influenza in Patients Receiving Intra-articular Corticosteroid Injections: A Cohort Study.

OBJECTIVE: Although intra-articular corticosteroid (IACS) is injected locally, some systemic absorption occurs, potentially causing immunosuppression in recipients. This study examined the odds of influenza in patients who received IACS compared with matched controls. DESIGN: Adults in the authors' health system who received IACS from May 2012 through April 2018 were 1:1 matched to adults without IACS. The primary outcome was overall odds of influenza. Secondary analyses examined influenza odds by timing of IACS, joint size, and vaccination status. RESULTS: A total of 23,368 adults (mean age, 63.5 yrs, 62.5% female) received IACS and were matched to a control. Although there was no difference in influenza odds by IACS status overall (odds ratio, 1.13; 95% confidence interval, 0.97-1.32), patients receiving IACS during influenza season had higher odds of influenza than matched controls (odds ratio, 1.34; 95% confidence interval, 1.03-1.74). Furthermore, unvaccinated patients who received IACS during influenza season had higher influenza odds compared with matched controls (odds ratio, 1.41; 95% confidence interval, 1.04-1.91]), whereas there was no difference among vaccinated patients. CONCLUSION: Patients receiving IACS injections during influenza season had higher odds of influenza. However, vaccination seemed to mitigate this risk. Patients receiving IACS injections should be counseled on infection risk and importance of vaccinations. Further research is needed to examine IACS effects on other viral illnesses. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Identify potential adverse effects of intra-articular corticosteroids; (2) Recognize risk factors for influenza diagnosis; and (3) Describe importance of influenza vaccination. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

Spinal corticosteroid injections are not associated with increased influenza risk.

BACKGROUND CONTEXT: Spinal corticosteroid injections (CSI) are often used to treat radicular and axial pain arising from the spine. Systemic corticosteroids are well known to cause immunosuppression, and locally injected spinal CSI are known to have some systemic absorption. However, it is unknown whether spinal CSI increases the risk of systemic viral infections, such as influenza. PURPOSE: To determine whether spinal CSI causes an increased risk for influenza infection and whether they reduce the protective effect of vaccination STUDY DESIGN/SETTING: A retrospective cohort study was performed at Kaiser Permanente Northern California, a large healthcare system with a diverse population. PATIENT SAMPLE: Adults (n=60,880) who received a spinal CSI during influenza seasons from 2016 to 2019. A comparison was made with 121,760 case-matched individuals who did not receive a spinal CSI. OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis following spinal CSI compared with case-matched controls. Secondary analysis examined odds of influenza diagnosis based on vaccination status, multiple same-day injections, and epidural versus non-epidural route of injection. METHODS: The electronic health record and associated research databases were analyzed to identify patients who received a spinal CSI during three consecutive flu seasons, 2016 through 2019. Injections were stratified into epidural versus non-epidural CSI and single injections versus multiple same-day injections. Additionally, the rate of influenza in vaccinated versus non-vaccinated individuals was examined. Inpatient flu diagnosis was used as a proxy for severe disease. After case matching was completed, odds ratios for flu diagnosis were calculated using a logistical regression model. RESULTS: The odds of flu diagnosis following spinal CSI were not increased compared with controls (OR 0.93 [0.87-1.01, 95% Wald CL]). For epidural CSI the OR was 0.91 (0.83-1.00, 95% Wald CL), and non-epidural it was 1.00 (0.89-1.13, 95% Wald CL). There were similar findings for multiple same-day injections and when looking at inpatient flu diagnosis. For vaccinated individuals, the OR for flu following spinal CSI was 0.86 (0.80-0.92, 95% Wald CL), which indicates a protective effect in these patients. CONCLUSIONS: Spinal CSI did not increase the odds of subsequently receiving a diagnosis of influenza, regardless of vaccination status, location of injection, single versus multiple same-day injection, or co-morbidity. Vaccination had a protective effect against influenza, and this was not adversely affected by receiving spinal CSI during the flu season.

Spinal region corticosteroid injections are not associated with increased risk for influenza.

BACKGROUND CONTEXT: Spinal region corticosteroid injections (CSI) are intended to act locally to relieve radicular or axial back pain, however some systemic absorption occurs, potentially placing recipients at risk for immunosuppressive effects of corticosteroids. No previous studies examine whether patients undergoing spinal region CSI are at increased risk for viral infections, particularly influenza-a common viral illness with potentially serious consequences, especially for patients with multimorbidity. PURPOSE: To examine odds of influenza in patients who received spinal region CSI compared to matched controls. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adults (n=9,196) who received a spinal CSI (epidural, facet, sacroiliac, paravertebral block) during influenza seasons occurring from 2000 to 2020 were 1:1 matched to controls without spinal CSI. OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis in spinal CSI patients compared to matched controls. Predetermined subgroup analyses examined odds of influenza diagnosis based on vaccination status and injection location. METHODS: An institutional database was queried to identify patients that received spinal CSI during influenza season (September 1 to April 30) from 2000 to 2020. Patients were matched by age, sex, and influenza vaccination status to controls without spinal CSI within the specified influenza season. Influenza diagnosis was ascertained using International Classification of Disease codes and data was analyzed using multiple logistic regression adjusted for comorbidities associated with increased risk for influenza. RESULTS: A total of 9,196 adults (mean age 60.8 years, 60.4% female) received a spinal CSI and were matched to a control. There were no increased odds of influenza for spinal CSI patients as compared to matched controls (OR 1.13, [95% CI, 0.86-1.48]). When subgroups were examined, there were also no increased odds of influenza for spinal CSI patients based on immunization status (unvaccinated or vaccinated) or spinal injection location (epidural or non-epidural). CONCLUSIONS: Spinal region CSI was not associated with increased odds of influenza or reduced vaccine efficacy. This is reassuring given the analgesic and functional restoration benefits of these injections. Assessing risk of viral infection associated with spinal CSI is particularly relevant in the era of the COVID-19 pandemic, and further work is needed to address this issue.

Joint Corticosteroid Injection Associated With Increased Influenza Risk.

Aging and immunocompromising conditions or medications may reduce influenza vaccine effectiveness. The high-dose vaccine has been used to improve vaccine response in patients 65 years and older. Because of systemic immunosuppressive effects, oral corticosteroids may reduce vaccine effectiveness; however, despite over half a century of use, no data are available regarding the effect of joint and bursa corticosteroid injection on influenza vaccine effectiveness. The aim of this retrospective study was to determine whether joint corticosteroid injection was associated with reduced influenza vaccine effectiveness. During the 5 influenza seasons between August 1, 2012, and March 31, 2017, a total of 15,068 major joint corticosteroid injections were given to patients residing in Olmsted County, Minnesota. Vaccinated patients receiving a major joint corticosteroid injection (n=4804) were at increased risk (relative risk, 1.52; 95% CI, 1.20-1.93) for developing influenza compared with vaccinated control patients. Women younger than 65 years were at the highest risk, suggesting that perhaps the high-dose vaccine should be considered for this group to enhance protection when possible.

Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants.

Anticoagulation is common in patients undergoing arthrocentesis and joint injections. Previous studies have established the safety of continuing anticoagulation with warfarin before joint aspirations/injections with only a small increased risk of bleeding, but no data are available regarding the use of direct oral anticoagulants (DOACs) and joint aspirations/injections. The objective of this study was to determine the rate of bleeding complications associated with arthrocentesis and joint injection in patients receiving DOACs. We performed a retrospective review of adult patients at Mayo Clinic in Rochester, Minnesota, who were being treated with DOACs and underwent outpatient joint aspiration and/or injection between October 1, 2010, and October 31, 2016. In 1050 consecutive procedures, there were no bleeding complications. Arthrocentesis and joint injections in patients receiving DOAC therapy are safe procedures, and there is no need to withhold anticoagulation treatment before the procedure.