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Why are steroid injections stopped during COVID?

During COVID lockdown there has been a national cessation on the delivery of intra-articular steroids, this has come at some cost to patients. Changes to their pain management strategy away from injection therapy to opiate based analgesia has come with its challenges. So why are steroid injection not recommended during a pandemic?

The diagram shows how the HPA axis. If the adrenal gland is suppressed or damaged it may not be able to make enough stress hormone cortisol in turn effecting blood pressure, blood glucose, metabolism and inflammation. This causes immune deficiency and puts the patient at comparatively greater risk when exposed to gastroenteritis, viral infection, emotional stress or perhaps elective surgery.

Why are steroid injection avoided during a pandemic?

The short answer is that steroid injections are avoided during a pandemic because research has shown that they can lead to an adrenal crisis, this is defined as a blood cortisol <100 nmol (normal is 300 nmol). Although Addisons disease is rare (primary adrenal insufficiency) it is expected that secondary and tertiary adrenal insufficiency are more common and perhaps missed in the healthcare setting. We need to be more aware and prepare our patients during consent by arming them with a steroid alert card.

Download the card

The delivery of intra-articular injections plays a role in the suppression of the HPA axis; Triamcinolone is ten times stronger than the naturally occurring glucocorticoid hormones and has a half life of 6 days and endures in the system for up to a month. During this period the negative feedback HPA axis will suppress the bodies natural secretion of cortisol by the adrenal gland, adrenocorticotropic hormone by the anterior pituitary gland, corticotropin releasing hormone by the Hypothalamus.

Once the steroid clearance has occurred, there is then a delay as the patients’ adrenals as they slowly begin coming back online, resulting in immune deficiency and subsequent illness.

Acute management of adrenal crisis

So what can be done? The acute management for an adrenal crisis is 100mg intramuscular hydrocortisone injection, or perhaps a intravenous injection 200mg/24hr hydrocortisone. Fluids are needed there possible orally but can be IV Sodium chloride 0.9%. Follow the sick day rules.

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