Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?
- W Neal Roberts, Jr, MD
W Neal Roberts, Jr, MD
- Chief of Rheumatology
- University of Lousiville
- Section Editor
- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Clinical professor, University of Washington, Seattle
- Clinical professor, University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific Arthritis Associates
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 . 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 . 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 .
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 . 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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- USE OF GLUCOCORTICOID INJECTIONS
- Choice of glucocorticoid preparation
- Variation of dose by anatomic location
- Should the glucocorticoid be mixed with a local anesthetic?
- Clinical considerations
- - Frequency of injection
- - Contraindications
- - Complications
- USE OF OTHER INJECTABLE AGENTS
- Hyaluronic acid derivatives
- Platelet-rich plasma injections
- Investigational agents
- SUMMARY AND RECOMMENDATIONS