Skip to main content
SpringerLink
Log in

A Risk-Benefit Assessment of Intra-Articular Corticosteroids in Rheumatic Disorders

  • Review Article
  • Published:
Drug Safety Aims and scope Submit manuscript

Abstract

The appeal of intra-articular corticosteroid therapy has increased with the growing emphasis on early disease control in rheumatoid disease. The impact on the patient’s pain and stiffness is impressive and prompt. This may encourage patient compliance with longer term therapies given to slow the course of the disease. The release of corticosteroid into the circulation also provides some generalised improvement. This can prove helpful during the management of flares of inflammatory disease.

There is less evidence to support the use of intra-articular corticosteroids in other inflammatory arthritides, but experience suggests that the benefits are similar. In osteoarthritis the benefits are less certain, but intra-articular therapy may prove important in patients who cannot undergo salvage operative procedures because of intercurrent illness.

The benefits of intra-articular corticosteroids may be enhanced by rest after the injection, or by the additional administration of agents such as radio-colloids, rifampicin (rifampin), or osmic acid. Most controlled trial data have been published on knee injections, but other joints can be useful targets for local therapy.

The risks are mainly related to the discomfort of the procedure, localised pain post-injection and flushing, but most feared is septic arthritis which probably occurs in about 1 in 10 000 injections. Careful aseptic technique is the best protection. Tissue atrophy at the injection site, abnormal uterine bleeding, hypertension and hyperglycaemia rarely cause problems. Osteonecrosis might be as much a problem with uncontrolled painful arthritis as with a joint rendered less symptomatic by corticosteroid injections.

Intra-articular corticosteroids form an important part of the management of inflammatory joint disease and might be considered where an inflammatory element occurs in osteoarthritis. They may be used at any stage in the arthritic process, but should be seen as an adjunct to other forms of symptom relief. In patients needing multiple joint injections, systemic therapy should be reviewed to see if better disease control could reduce the need for invasive therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hench P, Kendall EC, Slocumb CH, et al. The effects of a hormone of the adrenal cortex and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Mayo Clin Proc 1949; 24: 181–97

    CAS  Google Scholar 

  2. Hollander JL, Brown Jr EM, Jessar RA, et al. Hydrocortisone and cortisone injected into arthritic joints: comparative effects of and use of hydrocortisone as a local antiarthritic agent. JAMA 1951; 147: 1629–35

    Article  CAS  Google Scholar 

  3. Derendorf H, Mollmann H, Gruner A, et al. Pharmacokinetics and pharmacodynamics of glucocorticoid suspensions after intraarticular administration. Clin Pharmacol Ther 1986; 39: 313–7

    Article  PubMed  CAS  Google Scholar 

  4. Ward MM, Fries JF. Trends in antirheumatic medication use among patients with rheumatoid arthritis, 1981–1996. J Rheumatol 1998; 25: 408–16

    PubMed  CAS  Google Scholar 

  5. Blyth T, Hunter JA, Stirling A. Pain relief in the rheumatoid knee after steroid injection: a single-blind comparison of hydrocortisone succinate, and triamcinolone acetonide or hexacetonide. Br J Rheumatol 1994; 33: 461–3

    Article  PubMed  CAS  Google Scholar 

  6. Firestein GS, Paine MM, Littman BH. Gene expression (collagenase, tissue inhibitor of metalloproteinases, complement and HLA-DR) in rheumatoid arthritis and osteoarthritis synovium: quantitative analysis and effect of intraarticular corticosteroids. Arthritis Rheum 1991; 34: 1094–105

    Article  PubMed  CAS  Google Scholar 

  7. Pelletier J-P, Martel-Pelletier J. Cartilage degradation by neutral proteoglycanases in experimental osteoarthritis: suppression by steroids. Arthritis Rheum 1985; 28: 1393–401

    Article  PubMed  CAS  Google Scholar 

  8. Hollander JL. Intrasynovial corticosteroid therapy in arthritis. Md Med J 1970; 19: 62–6

    CAS  Google Scholar 

  9. Hollander JL, Jessar RA, Restifo RA, et al. A new intra-articular steroid ester with longer effectiveness [abstract]. Arthritis Rheum 1961; 4: 422

    Google Scholar 

  10. Kendall PH. Triamcinolone hexacetonide: a new corticosteroid for intra-articular therapy. Ann Phys Med 1967; 9: 55–8

    PubMed  CAS  Google Scholar 

  11. Derendorf H, Mollman HW, Barth J. Comparative pharmacokinetic evaluation of glucocorticoids after intra-articular administration [in German]. Aktuel Rheumatol 1990; 15: 145–53

    Article  Google Scholar 

  12. Balfour JA, Benfield P. Rimexolone. Biodrugs 1997; 7:158–63

    Article  PubMed  CAS  Google Scholar 

  13. McCarty DJ, Faires JS. A comparison of the duration of local anti-inflammatory effect of several adrenocorticosteroid esters — a bioassay technique. Curr Therapy Res 1963; 5: 284–90

    Google Scholar 

  14. McCarty DJ, Harman JG, Grassanovich JL, et al. Treatment of rheumatoid joint inflammation with intrasynovial triamcinolone hexacetonide. J Rheumatol 1995; 22: 1631–5

    PubMed  CAS  Google Scholar 

  15. Chakravarty K, Pharaoh PDP, Scott DGI. A randomised controlled study of post injection rest following intra-articular steroid therapy for knee synovitis. Br J Rheumatol 1994; 33: 464–8

    Article  PubMed  CAS  Google Scholar 

  16. Neustadt DH. Treatment of rheumatoid joint inflammation with intrasynovial triamcinolone. J Rheumatol 1997; 24: 1349–50

    Google Scholar 

  17. Chatham W, Williams G, Moreland L, et al. Intraarticular corticosteroid injections: should we rest the joints? Arthritis Care Res 1989; 2: 70–4

    Article  PubMed  CAS  Google Scholar 

  18. Sykes HR, Eyes B, Williams E, et al. The accuracy of blind intra-articular injections [abstract]. Br J Rheumatol 1994; 33 Suppl 1.: 132

    Google Scholar 

  19. Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ 1993; 307: 1393–40

    Google Scholar 

  20. Eustace JA, Brophy DP, Gibney RP, et al. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56: 59–63

    Article  PubMed  CAS  Google Scholar 

  21. Caldwell JR. Intra-articular corticosteroids: guide to selection and indications for use. Drugs 1996; 52: 507–14

    Article  PubMed  CAS  Google Scholar 

  22. Blyth T, Stirling A, Coote J, et al. Injection of the rheumatoid knee: does intra-articular methotrexate or rifampicin add to the benefits of triamcinolone hexacetonide? Br J Rheumatol 1998; 37: 770–2

    Article  PubMed  CAS  Google Scholar 

  23. Gordon MM, Blyth T, Hunter JA. A comparison of glenohumeral injections of triamcinolone acetonide (TA) and triamcinolone hexacetonide (TH) in the painful rheumatoid shoulder [abstract]. Br J Rheumatol 1995; 35 Suppl. 1: 78

    Google Scholar 

  24. Blyth TH, Irvine S, Paterson AS, et al. A comparison of orthoses [ankle foot orthosis (AFO) or Malleoloc] and steroid injections in the painful rheumatoid ankle. Scand J Rheumatol. 1998; Suppl. 108

  25. Belch JJF, McMillan NC, Fogelman I, et al. Combined phlebography and arthrography in patients with painful swollen calf. BMJ 1981; 282: 949

    Article  PubMed  CAS  Google Scholar 

  26. Kelly IGK. The source of shoulder pain in rheumatoid arthritis: its implications for surgery. J Shoulder Elbow Surg 1994; 3: 62–5

    Article  PubMed  CAS  Google Scholar 

  27. Blyth TH, Hunter JA. Treatment of the rheumatoid shoulder with intra-articular steroid; a comparison of superior and anterior routes of injection [abstract]. Br J Rheumatol 1993; 32 Suppl. 1: 69

    Google Scholar 

  28. Dixon AStJ, Graber J. Local injection therapy in rheumatic diseases. Basle: EULAR Publishers, 1989

    Google Scholar 

  29. Helliwell P, Woodburn J. Juvenile chronic arthritis: diagnosis and management of tibio-talar and sub-talar disease [letter]. Br J Rheumatol 1998; 37: 579

    Article  PubMed  CAS  Google Scholar 

  30. Mahler F, Fritschy D. Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. Br J Sports Med 1992; 26: 7–14

    Article  PubMed  CAS  Google Scholar 

  31. Owen DS. Aspiration and injection of joints and soft tissues. In: Kelley WN, Harris ED, Ruddy S, et al., editors. Textbook of rheumatology. 5th ed. Philadelphia: Saunders, 1997: 591–608

    Google Scholar 

  32. Plant MJ, Borg AA, Dziedzic K, et al. Radiographic patterns and response to steroid hip injection. Ann Rheum Dis 1997; 56: 476–80

    Article  PubMed  CAS  Google Scholar 

  33. Creamer P. Intra-articular corticosteroid injections in osteoarthritis: do they work and if so, how? Ann Rheum Dis 1997; 56: 634–6

    Article  PubMed  CAS  Google Scholar 

  34. Dieppe PA. Are intra-articular steroid injections useful for the treatment of the osteoarthitic joint [editorial]? Br J Rheumatol 1991; 30: 199

    Article  PubMed  CAS  Google Scholar 

  35. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis: part II: osteoarthritis of the knee: American College of Rheumatology. Arthritis Rheum 1995; 38: 1541–6

    Article  PubMed  CAS  Google Scholar 

  36. Balch HW, Gibson JMC, El-Ghobarey AF, et al. Repeated corticosteroid injections into knee joints. Rheumatol Rehab 1977; 11: 137–40

    Article  Google Scholar 

  37. Gaffney K, Ledingham J, Perry JD. Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis 1995; 54: 379–81

    Article  PubMed  CAS  Google Scholar 

  38. Jones A, Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response. Ann Rheum Dis 1996; 11: 829–32

    Article  Google Scholar 

  39. Friedman DM, Moore ME. The efficacy of intra-articular steroids in osteoarthritis: a double blind study. J Rheumatol 1980; 7: 850–6

    PubMed  CAS  Google Scholar 

  40. Dieppe P, Sathapatayavongs B, Jones H, et al. Intra-articular steroids in osteoarthritis. Rheum Rehab 1980; 19: 212–7

    Article  CAS  Google Scholar 

  41. Gray RG, Tenenbaum J, Gottlieb NL. Local corticosteroid treatment in rheumatic disorders. Semin Arthritis Rheum 1981; 10: 231–54

    Article  PubMed  CAS  Google Scholar 

  42. Maugars Y, Mathis C, Berthelot J-M, et al. Assessment of the efficacy of sacroiliac corticosteroid injections in spondyloarthropathies: a double blind study. Br J Rheumatol 1996; 35: 767–70

    Article  PubMed  CAS  Google Scholar 

  43. Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med 1991; 325: 1002–7

    Article  PubMed  CAS  Google Scholar 

  44. Huppertz H-I, Tschammler A, Horwitz A, et al. Intra-articular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth. J Paediatr 1995; 127; 317–21

    Article  CAS  Google Scholar 

  45. Green S, Buchbinder R, Glazier R, et al. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 1998; 316: 354–60

    Article  PubMed  CAS  Google Scholar 

  46. Szebenyi B, Dieppe P. Interventions to treat shoulder pain [letter]. BMJ 1998; 316: 1676

    Article  PubMed  CAS  Google Scholar 

  47. Patrick M, Doherty M. Facial flushing after intra-articular injection of steroid. BMJ 1987; 295: 1380

    Article  Google Scholar 

  48. Kahn CB, Hollander JL, Schumacher HR. Corticosteroid crystals in synovial fluid. JAMA 1970; 211: 807–9

    Article  PubMed  CAS  Google Scholar 

  49. McCarty DJ, Hogan JM. Inflammatory reaction after intrasynovial injection of microcrystalline adrenocorticosteroid esters. Arthritis Rheum 1964; 7: 359–67

    Article  PubMed  Google Scholar 

  50. Berger RG, Yount WJ. Immediate ’steroid flare’ from intra-articular triamcinolone hexacetonide injection: case report and review of the literature. Arthritis Rheum 1990; 33: 1284–6

    Article  PubMed  CAS  Google Scholar 

  51. Ostensson A, Geborek P. Septic arthritis as a non-surgical complication in rheumatoid arthritis: relation to disease severity and therapy. Br J Rheumatol 1991; 30: 35–8

    Article  PubMed  CAS  Google Scholar 

  52. Cawley PJ, Morris IM. A study to compare the efficacy of two methods of skin preparation prior to joint injection. Br J Rheumatol 1992; 31: 847–8

    Article  PubMed  CAS  Google Scholar 

  53. Alarcon-Segovia D, Ward LE. Charcot-like arthropathy in rheumatoid arthritis: consequence of overuse of a joint repeatedly injected with hydrocortisone. JAMA 1965; 193: 136–8

    Article  Google Scholar 

  54. Bentley G, Goodfellow JW. Disorganization of the knees following intra-articular hydrocortisone injections. J Bone Joint Surg 1969; 51B: 498–502

    Google Scholar 

  55. Chandler GN, Wright V. Deleterious effect of intra-articular hydrocortisone. Lancet 1985; II: 661–3

    Google Scholar 

  56. Laroche M, Arlet J, Mazieres B. Osteonecrosis of the femoral and humeral heads after intra-articular corticosteroid injections. J Rheumatol 1990; 17: 549–51

    PubMed  CAS  Google Scholar 

  57. Roberts WN, Babcock EA, Breitbach SA, et al. Corticosteroid injection in rheumatoid arthritis does not increase rate of total joint arthroplasty. J Rheumatol 1996; 23: 1001–4

    PubMed  CAS  Google Scholar 

  58. Butler M, Colombo C, Hickman L, et al. A new model of osteoarthritis in rabbits: III: evaluation of anti-osteoarthritic effects of selected drugs administered intraarticularly. Arthritis Rheum 1983; 26: 380–6

    Article  Google Scholar 

  59. Williams JM, Brandt KD. Triamcinolone hexacetonide protects against fibrillation and osteophyte formation following chemically induced articular cartilage damage. Arthritis Rheum 1985; 28: 1267–74

    Article  PubMed  CAS  Google Scholar 

  60. Pelletier J-P, DiBattista JA, Raynauld JP, et al. The in vivo effects of intraarticular corticosteroid injections on cartilage lesions, stromelysin, interleukin-1, and oncogene protein synthesis in experimental osteoarthritis. J Clin Lab Invest 1995; 72: 578–86

    CAS  Google Scholar 

  61. Pelletier J-P, Martel-Pelletier J, Cloutier JM, et al. Proteoglycan-degrading acid metalloprotease activity in human osteoarthritic cartilage, and the effect of intraarticular steroid injections. Arthritis Rheum 1987; 30: 541–8

    Article  PubMed  CAS  Google Scholar 

  62. Mankin HF, Conger KA. The acute effects of IA hydrocortisone on articular cartilage in rabbits. J Bone Joint Surg 1966; 48: 1383–8

    PubMed  CAS  Google Scholar 

  63. Gottlieb NL, Penneys NS, Brown Jr HE. Periarticular perilymphatic skin atrophy after intra-articular corticosteroid injections. JAMA 1978; 240: 559–60

    Article  PubMed  CAS  Google Scholar 

  64. Cunningham GR, Goldzieher JW, de la Pena A, et al. The mechanism of ovulation inhibition by triamcinolone acetonide. J Clin Endocrinol Metab 1978; 46: 8–14

    Article  PubMed  CAS  Google Scholar 

  65. Emkey RD, Lindsay R, Lyssy J, et al. The systemic effect of intra-articular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis. Arthritis Rheum 1996; 37: 277–82

    Article  Google Scholar 

  66. Gerster JC, Fallet GH. Periarticular hydroxyapatite deposition after corticosteroid injections. J Rheumatol 1987; 14: 1156–9

    PubMed  CAS  Google Scholar 

  67. Schuster S, Williams IA. Adrenal suppression due to intra-articular steroid therapy. Lancet 1961; II: 171

    Article  Google Scholar 

  68. Reid DM, Eastmond C, Rennie JAN. Hypothalamic-pituitary-adrenal suppression after repeated intra-articular injection. Ann Rheum Dis 1986; 45; 87

    Article  PubMed  CAS  Google Scholar 

  69. Esselinckx W, Kolanowski J, Ngant de Deuxchaisnes CH. Adrenocortical function and responsiveness to tetracosactrin infusions after intra-articular treatment with triamcinolone acetonide and hydrocortisone acetate. Clin Rheumatol 1982; 1: 176–84

    Article  PubMed  CAS  Google Scholar 

  70. Lazarevic MB, Shosey JL, Djordjevic-Denic G, et al. Reduction of cortisol levels after single intra-articular and intramuscular injections. Am J Med 1995; 99: 370–3

    Article  PubMed  CAS  Google Scholar 

  71. Committee on Safety of Medicines/Medicines Control Agency. Systemic corticosteroids in pregnancy and lactation. Curr Probl Pharmacovig 1998; 24: 9

    Google Scholar 

  72. Thumboo J, O’Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum 1998; 41: 736–9

    Article  PubMed  CAS  Google Scholar 

  73. Pal B, Nash EJ, Oppenheim B, et al. Routine synovial fluid culture: is it necessary? Lessons from an audit. Br J Rheumatol 1997; 36: 1116–7

    Article  PubMed  CAS  Google Scholar 

  74. Sharma A, Baethge BA, Acebes JC, et al. Arthroscopic lavage treatment in rheumatoid arthritis of the knee. J Rheumatol 1996; 23: 1872–4

    PubMed  CAS  Google Scholar 

  75. Gumpel JM, Roles NC. A controlled trial of intra-articular radiocolloids versus surgical synovectomy in persistent synovitis. Lancet 1975; I: 488–9

    Article  Google Scholar 

  76. Gumpel JM, Matthews SA, Fisher M. Synoviorthesis with erbium-169: a double-blind controlled comparison of erbium-169 with corticosteroid. Ann Rheum Dis 1979; 38: 341–3

    Article  PubMed  CAS  Google Scholar 

  77. Anttinen J, Oka M. Intra-articular triamcinolone hexacetonide and osmic acid in persistent synovitis of the knee. Scand J Rheumatol 1975; 4: 125–8

    Article  PubMed  CAS  Google Scholar 

  78. Bird HA, Ring EFJ, Daniel R, et al. Comparison of intra-articular methotrexate with intra-articular triamcinolone hexacetonide. Curr Med Res Opin 1977; 5: 141–6

    Article  PubMed  CAS  Google Scholar 

  79. Hall GH, Jones BJM, Head AC. Intra-articular methotrexate. Clinical and laboratory study in rheumatoid and psoriatic arthritis. Ann Rheum Dis 1978; 37: 351–6

    Article  PubMed  CAS  Google Scholar 

  80. Wobig M, Dickhut A, Maier R, et al. Viscosupplementation with hylan G-F 20: a 20 week controlled trial of efficacy and safety in the osteoarthritic knee. Clin Ther 1998; 20: 410–23

    Article  PubMed  CAS  Google Scholar 

  81. Goebel KM, Storck U, Neurath F. Intra-synovial orgotein therapy in rheumatoid arthritis. Lancet 1981; I: 1015–17

    Article  Google Scholar 

  82. Gammer W, Broback LG. Clinical comparison of orgotein and methylprednisolone acetate in the treatment of osteoarthritis of the knee joint. Scand J Rheumatol 1984; 13: 108–12

    Article  PubMed  CAS  Google Scholar 

  83. Goebel KM, Storck U. Effect of intra-articular orgotein versus corticosteroid on rheumatoid arthritis of the knees. Am J Med 1983; 74; 124–8

    Article  PubMed  CAS  Google Scholar 

  84. Kirwan JR, Arthritis and Rheumatism Council Low Dose Glucocorticoid Study Group. The effect of glucocorticoids on joint destruction in rheumatoid arthritis. N Engl J Med 1995; 333: 142–6

    Article  PubMed  CAS  Google Scholar 

  85. Haslock I, MacFarlane D, Speed C. Intra-articular and soft tissue injections: a survey of current practice. Br J Rheumatol 1995; 34: 449–52

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Rheumatology, Gartnavel General Hospital, Glasgow, Scotland

    John A. Hunter & Thomas H. Blyth

Authors
  1. John A. Hunter
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas H. Blyth
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hunter, J.A., Blyth, T.H. A Risk-Benefit Assessment of Intra-Articular Corticosteroids in Rheumatic Disorders. Drug-Safety 21, 353–365 (1999). https://doi.org/10.2165/00002018-199921050-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002018-199921050-00002

Keywords

Search

Navigation