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Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?

Author
W Neal Roberts, Jr, MD
Section Editor
Daniel E Furst, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH

INTRODUCTION

This topic will review specific aspects of intraarticular and soft tissue glucocorticoid injections, including the dose and selection of the glucocorticoid preparation as well as some general clinical considerations. We will also discuss the role of other injectable agents. The technique, indications, and complications that can occur with intraarticular and periarticular injections of glucocorticoids are discussed separately. (See "Joint aspiration or injection in adults: Technique and indications" and "Joint aspiration or injection in adults: Complications".)

Intraarticular injections of chemicals or short-lived radionuclides, which are sometimes used as an alternative to surgical synovectomy, are discussed elsewhere (see "Synovectomy for inflammatory arthritis of the knee"). Injections for subacute and chronic low back pain are also discussed separately. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment", section on 'Glucocorticoid and other injections'.)

USE OF GLUCOCORTICOID INJECTIONS

Glucocorticoid injections are commonly used to treat painful musculoskeletal conditions, but there is a lack of consensus regarding their efficacy for various conditions [1]. Some of the more common uses for depot glucocorticoid injections include inflammatory arthritides, tendinopathies, and nerve compression syndromes, which are discussed in detail within the specific topic reviews.

Pharmacology — Some of the major differences among the depot glucocorticoid preparations pertain to differences in solubility, crystal structure, and duration of action, as well as other aspects of the chemical structure [2]. Solubility is an important characteristic because compounds with lower solubility are thought to remain at the injected site for longer periods of time and result in lower systemic levels when compared with a compound of higher solubility. However, there are some data to suggest that decreased solubility does not always correlate with a more sustained clinical effect. As an example, in a randomized trial comparing the effectiveness of triamcinolone hexacetonide and methylprednisolone acetate in patients with a symptomatic knee osteoarthritis (OA), methylprednisolone acetate appeared to have longer-lasting effects even though it is a comparatively more soluble compound [3].

The crystal structures of the different glucocorticoid preparations also vary and can sometimes be difficult to distinguish from other intraarticular crystals related to an inflammatory arthritis such as monosodium urate (MSU), calcium pyrophosphate dihydrate, and hydroxyapatite [4]. In addition to the actual glucocorticoid, there are other chemical ingredients and changes in the preparation such as the preservatives as well as the addition of a fluorine group. Flocculation of the glucocorticoid (precipitation of glucocorticoid crystals out of solution into a less bioavailable paste) can occur with addition of the methylparabens used as bacteriostatic agents in the local anesthetic.

            
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Literature review current through: Nov 2017. | This topic last updated: Nov 29, 2017.
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References
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