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.
  • 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  • Long-term steroids should be withdrawn gradually.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.