Are these legitimate arguments?
1) One shot should fix it and if it doesn’t then that’s it (I call this the “one shot wonder” attitude). I think the only person who could be sure to fix things at one go would have to be God and I know I’m not him/her…
2) Steroid injection rots the cartilage from joints and accelerates osteoarthritis. If steroid injections are used to treat symptomatic mensicial tears, I would not think repeated injections would not be the best idea as accelerated deterioration would be happening anyway.
But evidence do we have?
1) Repeated shots sustain improvement without joint deterioration over two years:
Arthritis Rheum. 2003 Feb;48(2):370-7.
Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial.
Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, Uthman I, Khy V, Tremblay JL, Bertrand C, Pelletier JP.abstract
- injections of triamcinolone acetonide 40 mg (34 patients) or saline (34 patients) into the study knee every 3 months for up to 2 years.
- no xray changes
- “knee pain and stiffness were significantly improved throughout the 2-year study by repeated injections of triamcinolone acetonide, but not saline (P < 0.05)"
- no deleterious effects
- As one can see below, the shots seem to last a few months and a repeat shot sustains it:Plots of improvement:
Cochrane confirms short term benefits but states” The short-term benefit of IA corticosteroids in treatment of knee OA is well established, and few side effects have been reported. Longer term benefits have not been confirmed based on the RevMan analysis. – I suspect what they are saying is they don’t know much beyond fact repeated shots are necessary to maintain benefits.
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD005328. Update of: Cochrane Database Syst Rev. 2005;(2):CD005328. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.
The repeated shot article did seem to set a new standard for care: A recent Cleveland clinic article stated: ” Steroid injections may be given up to three or four times per year. ”
2) Hip shots are helpful:
Arthritis Rheum. 2007 Jul;56(7):2278-87.
Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Lambert RG, Hutchings EJ, Grace MG, Jhangri GS, Conner-Spady B, Maksymowych WP.
Following hip injection they stated:
“Following injection ofthe hip, the patient was instructed to rest, preferably in the form of bed rest, for 3 days and to maintain at least minimal activity. After this 3-day period, activity was restricted for 1 week, during which the patient was asked to refrain from active exercise and, if possible, to refrain from work.”
Their conclusion was:
” This placebo-controlled trial confirms that corticosteroid injection can be an effective treatment of pain in hip OA, with benefits lasting up to 3 months in many cases. Future studies should address questions related to the benefits of repeated steroid injection and the effects of this treatment on disease modification. ”
I have a lady with a bad hip that one injection gave sustained relief – of course it helped that she was light-weight…
Comment – It looks like the new standard is to repeat shots in the knee four times a year but the hip is anyone’s guess. The safe dose was 40 mg Triamcinolone – not 80 mg like I have seen rheumatology use..
Any comments here?