10.1.2.2 Local corticosteroid injections
|1st choice||Intra-articular injection:|
Methylprednisolone acetate (Depo-Medrone®) vials 40mg/mL, 80mg/2mL, 120mg/3mL
Intra-articular injection, 4-80mg according to size and severity.
- 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 firstname.lastname@example.org.
- 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- Long-term steroids should be withdrawn gradually.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
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.