Home Formulary 10.0 Musculoskeletal and Joint Diseases 10.1 Drugs use in rheumatic diseases and gout 10.1.2 Corticosteroids 10.1.2.2 Local corticosteroid injections

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10.1.2.2 Local corticosteroid injections

ChoiceDrugDosage
1st choiceIntra-articular injection:
Methylprednisolone acetate (Depo-Medrone®) vials 40mg/mL, 80mg/2mL, 120mg/3mL		Dose:
Intra-articular injection, 4-80mg according to size and severity.
Or

Triamcinoline acetonide
(Adcortyl® Intra-articular) injection 10mg/mL,
(Kenalog® Intra-articular) injection 40mg/mL

Dose:
Adcortyl® Intra-articular by intra-articular injection, 2.5mg–15mg according to size (for larger doses use Kenalog®)

Kenalog® Intra-articular injection 40mg/mL: by intra-articular injection, 5-40mg according to size; total max 80mg

  • There is no consistent evidence for an ideal steroid regimen that is suitable for all patients. Therefore, the approach to treatment must be flexible and tailored to the individual.
  • If a patient is to receive corticosteroid treatment for longer than 3 weeks then they should be provided with written information and given the opportunity to discuss the benefits and risks of long-term corticosteroids before treatment is commenced. Patient information leaflets are widely available e.g. from http://www.arthritisresearchuk.org/ and a steroid card should be given where appropriate. Community pharmacies and GP practices can order these from pharmacystationeryorders@hscni.net.
  • An additional Steroid Emergency Card for Northern Ireland has been developed in response to the National Patient Safety Alert that was issued in August 2020. The alert highlights the dangers associated with adrenal insufficiency for patients taking corticosteroid medication, and recommends that all eligible patients prescribed (or initiated on) steroids are assessed and where necessary issued with a Steroid Emergency Card. Community pharmacies and GP practices can order these from pharmacystationeryorders@hscni.net
  • Prophylactic bone protection should be considered in patients anticipated to receive long term corticosteroid treatment (e.g. any dose of prednisolone daily for longer than 3 months). Refer to Royal College of Physicians treatment algorithm.
  • Long-term steroids should be withdrawn gradually.
  • Full aseptic precautions are essential when giving intra-articular injections.
  • The British Society for Rheumatology recommends initiation of low-dose steroid therapy with gradually tailored tapering in straightforward polymyalgia rheumatica (PMR). Refer to guidelines here.

Giant cell arteritis

  • For giant cell arteritis (GCA), the BSR recommends the immediate initiation of high-dose glucocorticosteroid treatment after clinical suspicion of GCA is raised.
  • The consensus for glucocorticosteroid initiation is as follows:

Uncomplicated GCA (no jaw or tongue claudication or visual symptoms):

  • immediate discussion with or referral to rheumatology is recommended
  • prednisolone 40-60mg daily until resolution of symptoms and laboratory abnormalities

Complicated GCA (presence of visual symptoms):

  • immediate referral to Ophthalmology is essential if there is visual loss for consideration of IV methylprednisolone

Hayfever

Depot corticosteroid injections (e.g. Kenalog®) are not recommended for the management of hayfever in primary care due to potential to cause prolonged effects and any adverse effects are difficult to reverse. See chapter 3.4.1.