Safety of Corticosteroid Injections for Pain During the COVID-19 Pandemic

There remains insufficient data defining the potential risk for severe illness associated with epidural or intra-articular corticosteroid injections when contracting coronavirus disease 2019 (COVID-19). These perspectives were published in Pain Medicine.

Study authors sought to clarify whether steroid injections alter risk in the context of the COVID-19 pandemic.

It has been established that therapeutic corticosteroid use may adversely affect both the innate and adaptive immune response. After injection, neutrophil migration is impaired, and macrophage and monocyte function may be inhibited.

The endocrine system has been shown to be similarly perturbed by epidural corticosteroid injections. A week after injection, the hypothalamic–pituitary–adrenal (HPA) axis remains suppressed depending on the dose, by 86% for larger doses (80 mg) and 53% for smaller doses (40 mg).

Intra-articular corticosteroid injections results in similar HPA suppression for up to 4 weeks. Cortisol levels drastically reduce from baseline (329.55 nmol/L to 72.99 nmol/L) a week after injection.

Although administration of corticosteroids remains untested during the global pandemic, the established immunosuppressive side effects are concerning. Despite these facts, the need for interventional pain procedures remains, and in some situations, may still be indicated. The Centers for Medicare & Medicaid Services has advised clinicians that among patients with severe pain, treatment may proceed during the current pandemic.

When scheduling an injection treatment, clinicians should take local infection rates, location of service, and availability of personal protective equipment into consideration. Each patient should be assessed for their individual risk for COVID-19. The US Centers for Disease Control and Prevention has identified people who have an increased infection risk, including people aged >65, obesity, those who live in long-term care facilities, those who have chronic comorbidities, those who have a compromised immune system.

The article authors concluded with suggestions for clinicians. Treatment with corticosteroids should be deferred or delayed until the pandemic conditions improve, when possible.

When corticosteroid administration is considered, patients should be made aware of all potential risks from immunosuppression during the COVID-19 pandemic and may self-select for delayed treatment. Side effects to the immune and endocrine system appear to be dose-dependent, so lower doses may mitigate potential negative side effects.

Dexamethasone has been shown to have shorter a duration of systemic effects and may be the most favorable choice during the current pandemic.

Reference

Miller DC, Patel J, Gill J, et al. Corticosteroid injections and COVID-19 infection risk. Published online July 22, 2020. Pain Med. doi: 10.1093/pm/pnaa199