What are Corticosteroids?
Corticosteroid is a hormone produced by adrenal cortex. Adrenal cortex secrets two kinds of corticosteroids called glucocorticoids (corticosterone, cortisone) and mineralocorticoids (aldosterone). Concentration of corticosteroid hormones is higher in serum following response to stress and inflammation. Glucocorticoid hormone regulate carbohydrate and protein metabolism. Mineralocorticoids (aldosterone) maintain level of sodium by regulating absorption of sodium in kidneys.
Corticosteroid is been used in as therapeutic medications since 1944.
1950 - Tadeusz Reichstein, Edward Kendall and Philip Hench were awarded Noble prize of Physiology and Medicine for their work on adrenal cortex and hormones secreted by adrenal cortex.
Corticosteroids are anti-inflammatory and distinctly different from the anabolic steroids. Anabolic steroid acts like testosterone and increases intracellular synthesis of protein in muscle cells.
Corticosteroids are not anabolic steroid neither has side effects same as anabolic steroids.
Synthetic gluco-corticosteroids are dexamethasone, prednisone, prednisolone, methylprednisolone, triamcinolone, beclometasone, flurocricosterone acetate and deoxycorticosteone acetate.
Mineralocorticoids are fludrocortisone (florinef) and aldosterone.
Mechanism of Action
Steroids works by decreasing inflammation and reducing the activity of the immune system. Steroids are used to treat a variety of inflammatory diseases and conditions
Route of Administration
- Interventional - targeted injection of corticosteroid near inflamed tissue. Advantage is least amount of cortisone is injected. Treatment can be repeated as necessary. Response to treatment is rapid.
- Intravenous or IV - therapeutic effects can be achieved by minimum effective dosage. Dosage is 6 times more than interventional targeted injection of inflames tissue.
- Intramuscular - absorption is often inconsistent.
- Oral - tablets size depends on dosage quantity.
- Eye drops - local drops use for non-infectious inflammation and autoimmune disease affecting eyes like glaucoma.
- Ear drops - used for itching and allergies causing sterile non-infectious inflammation.
- Creams - local application for skin diseases mostly autoimmune and allergic diseases. Also used for bursitis of hand, feet, fingers and toes. Superficial bursitis responds to local cortisone application.
- Anti-inflammation - Rhinitis, arthritis, temporal arteritis and dermatitis
- Anti-allergic - Dermatitis, psoriasis, rhinitis, asthma, glaucoma and uveitis
- Bronchospasm - Bronchospasm not responding to other medications is treated with inhalation or I.V. corticosteroids
- Autoimmune disease - Hepatitis, Systemic lupus erythematosus and sarcoidosis
- Inflammatory bowel disease - Ulcerative colitis, Crohn's disease
- Addison's disease (adrenal insufficiency)
- Traumatic brain injury - Cerebral edema
- Nausea - Ondansetron is a synthetic corticosteroids specifically used for nausea not responding to other anti nausea medications.
Side Effects of Corticosteroids
- Cushing's syndrome (drug induced)
- Hypertension (mineralocorticoid effect prednisone)
- Low potassium (hypokalemia)
- High sodium (hypernatremia)
- Metabolic alkalosis
- Insulin resistance diabetic mellitus
- Connective tissue weakness
- Cognitive symptoms may develop like depression and anxiety
- Erectile dysfunction
Corticosteroids are contraindicated in pregnancy even though clinical research indicates low teratogenic effect.
Most common cortisone use for interventional procedures are depot medrol (dexamethasone), kanalog (triamcinolone) and celestine (betamethasone). They all have similar mechanisms although they vary in strength and duration of action. Triamcinolone and dexamethasone are intermediate acting and betamethasone are long acting synthetic corticosteroids. No single preparation has been found to be superior to others so the choice of medication is left up to physician. Following are the list of procedures. Each section has multiple joints, muscles, tendons, nerves and ganglion. There are several procedures performed to relieve pain and inflammation. Training, experience, understanding of anatomy and accurate diagnosis is essential to accomplish optimum results. Injection of synthetic cortisone close to inflame tissue is an invasive procedure. Neurosurgeon, orthopedic surgeon, interventional pain specialist and rehab physical medicine specialist perform procedures. Primary care physicians also do few trigger point injections in their office.
Injections are performed as a diagnostic and therapeutic injection. Diagnostic injections are performed to diagnosed and differentiate the cause of pain from nerve, joint, tendon or muscles.
Procedures are performed in surgical center or outpatient surgery facilities. Clean environment, sterilized instruments and sterilized supply must be used to prevent systemic and contact infection. Procedure may be performed under sedation if necessary depending on difficulties of procedure and patient's tolerance to needle as well as prone position. Skin condition should be checked prior to scheduling patient for procedure. Procedure is postponed if patient is having skin rash, bruises skin infection or and systemic infection. Skin should be shaved if necessary prior to procedure. Skin is prepped to remove bacteria, dirt and skin oil. Skin is prep by using chloroprep or duraprep according to recommendation and guidelines set by manufacturer.
Synthetic corticosteroid is injected close to inflame tissue causing severe pain. Needle is placed close to inflame tissue under guidance of X-ray. Appropriate amount of synthetic cortisone mix with local anesthetic such as lidocaine or bupivacaine is injected after dye study. Dye study is performed to confirmed position of needle. Patient is observed in recovery room for any post surgery complication before discharged home. Patient is discharged home with a driver and post op instructions.
Broad Classification of Interventional Pain Procedures
Each section described below has several muscles, tendons, nerves and ganglions generating several procedures depending on cause of pain.
- Trigger point injection
- Tendon injection
- Joint injection
- Epidural injection
- Peripheral Nerve block
- Paravertebral nerve block
- Cranial nerve block
- Sympathetic ganglion block
- Parasympathetic nerve block
Synthetic Injectable Steroids
- Inflammatory Muscle Diseases - Fibromyalgia, myalgia, myofascial pain syndrome, muscle sprain.
- Joint and Bone Disease - Arthritis, gout, rheumatoid arthritis, osteoarthritis, tennis elbow.
- Tendon Pain - Bursitis caused by inflammation of bursa around tendons near shoulder, elbow, hip, knee, hand, or wrist joints, stenosing tenosynovitis, De Quervain's tendonitis, carpal tunnel syndrome and rotator cuff tendonitis.
- Nerve Pain - Peripheral neuropathy, diabetic neuropathy, post herpetic neuralgia, radiculopathy, paraspinal nerve pain, trigeminal neuralgia, occipital neuralgia, ulnar neuropathy, entrapped peripheral nerves in chest, abdominal wall, upper and lower extremities, sciatica and intercostal neuralgia.
- Initial pain relief - Onset of initial pain relief is within few minutes and may last for 1 to 4 hours. Initial pain relief is secondary to effects of local anesthetics, which is used in combination with cortisone.
- Prolong pain relief - Duration is 1 to 3 weeks. Pain relief lasting 2 weeks or longer is secondary to anti-inflammatory action of cortisone.
- Severe inflammation - Some of the diseases causing severe pain may be treated with several injection to achieve prolong analgesia so patient can performed rehab and physical therapy which is beneficial in long-term prognosis.
- Guidelines - There are several guidelines are written by various pain societies and organization. How many injections- weekly monthly, too many- damage tendon and cartilages.
Complications After Injection
- Abscess and infection.
- Allergic reactions.
- Local bleeding.
- Rupture of a tendon.
- Skin discoloration.
- Hot flashes - Few patients may suffer with uncomfortable hot flashes after cortisone injection for 2 to 3 days. Symptom can be less intense after treatment with antihistaminic.
- Skin discoloration - Occasional multiple injection or rarely single injection can cause whitening of skin discoloration around the injection area. The discoloration many temporary or permanent.
- Hyperglycemia - Blood sugar may be high mostly in diabetes patients. Blood sugar level is always checked before patient is discharged home and if blood sugar is high then level is treated with appropriate medication which may include subcutaneous injection of insulin.
- Hypertension - Patient with history of hypertension may indicate high blood pressure, which responds to medications and treated before patient is discharged home.
Monitoring During and After Procedure
- Blood pressure.
- Heart rate.
- Pain score.
- Blood sugar.
- Skin Infection.
- Skin Lesion.
- Systemic Infection - Pharyngitis, bronchitis, pneumonia and fever.
- Bleeding Problem - Patient taking anticoagulants may bleed during and after needle puncture and penetration. Patient is investigated and treated prior to procedure to prevent external and internal bleeding.