Clinical Rheumatology

, 28:85

The effect of intra-articular injection of betamethasone acetate/betamethasone sodium phosphate on blood glucose levels in controlled diabetic patients with symptomatic osteoarthritis of the knee

Authors

    • Rheumatology ClinicNazareth Hospital
    • Department of MedicineCarmel Medical Center
    • Faculty of MedicineTechnion, Israel Institute of Technology
  • Ahmed Safia
    • Clalit Health Services
Brief Report

DOI: 10.1007/s10067-008-1023-9

Cite this article as:
Habib, G. & Safia, A. Clin Rheumatol (2009) 28: 85. doi:10.1007/s10067-008-1023-9

Abstract

To evaluate the effect of intra-articular steroid injection (IASI) of betamethasone acetate/betamethasone sodium phosphate (Celestone Chronodose) at the knee joint on blood glucose and fructosamine levels in controlled diabetic patients with osteoarthritis of the knee. Controlled diabetic patients (HgA1C < 7) with symptomatic osteoarthritis of the knee who failed medical and physical therapy and use modern versions of home-monitoring blood glucose devices were offered an IASI of Celestone Chronodose at the knee joint. If agreed, patients were asked to document blood glucose levels before and 2 h after meals for 1 week prior to IASI and daily for 4 days then every other day for 10 days following IASI of 1 ml of Celestone Chronodose. Serum fructosamine levels were obtained just prior and 2 weeks following the injection. Six patients completed the study and all had a significant brisk elevation of blood glucose levels within the first hour lasting for less than 48 h in five of them. Mean glucose level 1 h following the injection was 218.33 ± 41.75 mg% and mean maximal level 322.5 ± 67.75 mg%. There was no significant change in fructosamine levels. IASI of Celestone Chronodose will transiently increase blood glucose levels in diabetic patients. It has no significant effect on serum fructosamine levels.

Keywords

BetamethasoneDiabetesFructosamineGlucoseIntra-articularSteroids

Introduction

Intra-articular steroid injection (IASI) is a very common and useful therapeutic modality for symptomatic osteoarthritis of the knee (OAK) [1]. As in systemic treatment, adverse effects following IASI were reported [2, 3]. There is no data on the effect of IASI of betamethasone depot preparations at the knee joint on blood glucose levels, yet we know that substantial concentrations of betamethasone following IASI of betamethasone-depot preparation at the knee joint were found in the plasma [4]. Celestone Chronodose is one type of betamethasone depot preparations (Schering-Plough, N.V., Belgium). It is composed of two components: betamethasone acetate and betamethasone sodium phosphate. In this study, we wanted to evaluate prospectively the effect of 1 ml of Celestone Chronodose injection (3 mg of each component) at the knee joint on blood glucose and serum fructosamine levels in controlled diabetic patients with symptomatic OAK.

Materials and methods

Controlled diabetic patients (HgA1C < 7) using modern version of blood glucose monitoring devices, with knee pain due to OAK [5] without sufficient response to medical and physical therapy, no previous IASI at the knee joint, and no steroid treatment during the last 3 months, were offered an IASI of 1 ml of Celestone Chronodose. If agreed, patients were asked to monitor their blood glucose before and 2 h after breakfast, lunch, and supper every other day during 1 week prior to injection and daily for 4 days, then every other day for 10 days following the injection, and also 1 h after the injection. Serum fructosamine levels were obtained just prior to and 2 weeks following the IASI. All the IASIs were done in the morning 1 h following breakfast after maximal aspiration of knee fluid if any. Patients were asked to continue the same regimen of physical activity, diet, and antidiabetic treatment. Significant increase in blood glucose level after the injection was considered if the level was higher by at least 2 standard deviations (SDs) than the mean comparable (in reference to meals) glucose level before the injection. Wilcoxon’s test was use to compare serum fructosamine levels obtained 2 weeks following the injection to those obtained just prior to injection. The study was approved by the Helsinki Committee of the Nazareth Hospital and all the patients signed a consent form.

Results

Clinical, laboratory, and epidemiologic data of the patients are shown in Table 1. None of the patients added or stopped any medication or reported any symptom/sign suggestive of an intercurrent infection. Table 2 shows blood glucose values at different times. The significant increase in blood glucose levels affected both pre- and postprandial measurements of all meals. Following the increase, glucose levels declined to levels similar to those prior to the injection. There was no significant difference between fructosamine levels obtained 2 weeks following the IASI compared to those obtained prior to the injection (Z = −0.734, p = 0.463).
Table 1

Epidemiologic, clinical, and laboratory parameters of the patients

Parameter

Number (%)

Patients with type-2 diabetes

6 (100)

Female to male

4:2

Age (mean ± SD, range; years)

66.8 ± 11.1, 50–79

Duration of diabetes (mean ± SD, range; years)

9.16 ± 8.61, 1–20

Duration of knee symptoms (mean ± SD, range; years)

8.6 ± 7.1, 1–20

HgA1C (mean ± SD, range)

6.43 ± 0.53, 5.4–6.9

Patients’ treatment; diet only

2

Oral hypoglycemic

3

Insulin only

1

Knee effusion (mild)

2

Table 2

Time relation of glucose levels following IASI of Celestone Chronodose and fructosamine levels prior and following IASI

Patient

Time to earliest significantly increased glucose level (h)

Earliest significantly increased glucose level (mg%)

Time to peak glucose levels (h)

Peak glucose levels (mg%)

Time to return to baseline levels (h)

Fructosamine level before IASI

Fructosamine level after IASI

1

1

198

6

339

18

259

286

2

1

180

34

251

34

321

335

3

1

207

6

313

46

332

297

4

1

298

2

351

46

410

351

5

1

201

32

430

72

287

290

6

1

226

2

251

25

323

303

Discussion

So, for the first time, it is shown that IASI of Celestone Chronodose at the knee joint will most probably increase blood glucose levels in controlled diabetic patients with OAK. The pattern of increase is quite uniform with an immediate increase in blood glucose levels lasting mostly for less than 2 days following the injection. These results reflect the fast absorption of betamethasone from the knee joint with a short half-life as had been shown by the study of Gless et al. [4].

Although fructosamine reflects mean blood glucose values over a period of 1–2 weeks [6], it seems that the amount and duration of glucose level changes do not produce enough “area under the curve” of increased glucose levels that ultimately leads to a significantly increased fructosamine levels. The major shortcoming of our study is the small number of our patients; however, the consistent findings of increased blood glucose levels following the IASI gives us a clear indication to what will happen to so many diabetic patients, who are candidate for a such common modality of treatment, and will ask the legitimate question that till now had no answer “Doc, will the injection affect my diabetes?”.

Disclosures

None.

Copyright information

© Clinical Rheumatology 2008