Do corticosteroid injections change any risks of COVID-19?  

Posted on August 5, 2020 by Madalon Burnett

Summary

A variety of national boards and societies recommend caution in providing corticosteroid injections during the pandemic because of risks of immunosuppression. There is a review article available on this topic. In general, recommendations are to use shared decision making with patients when offering a corticosteroid injection during the pandemic.

I.   Review of Evidence

  • Bone and Joint Open journal offers an excellent review article on this topic (1). Their main recommendation is: 
    • “With careful shared decision-making, recognizing the potential but, in all probability, very low risks of [corticosteroid injection] in the setting of COVID-19, and after appropriate patient selection and counselling, we feel continued use of CSI in low doses remains an appropriate treatment option for many patients
    • To support this recommendation, the authors offer the following: 
      • Various national bodies have recommended against corticosteroid injections at this time due to evidence that systemic corticosteroids influence infection with Middle East Respiratory Syndrome, Severe Acute Respiratory Syndrome and influenza
      • Looking more specifically at injections of corticosteroids: 
        • Epidural corticosteroid injections causes adrenal suppression but only 1/149 participants experienced an event (pneumonia) that could indicate immunosuppression (The authors cite (2))
        • A review article on use of corticosteroids in rheumatic conditions found “evidence from randomized controlled trials (RCTs) showed ‘no significant increased risk of infection was noted in the corticosteroid arms in most of the trials”, though some observational studies reported a dose-related increase in infection (The authors cite (3))
        • If a patient is known to be infected and hospitalized with COVID-19, then a corticosteroid injection is not recommended based on articles from the Lancet (authors cite (4) and (5))
        • There is a 1/1000 increased risk of developing influenza if the patient has had a corticosteroid injection (authors cite (6))

II.   Selection of Society Recommendations

  • The NHS recommends (7): 
    • “Don’t stop current steroids but taper their dose if possible and if it is clinically safe to do so, in line with usual practice
    • Think before starting steroids in the current pandemic.
    • Use the lowest possible dose of oral steroids for the shortest period of time
    • Only give a steroid injection if a patient has significant disease activity and/or intrusive and persisting symptoms, and there are no appropriate alternatives”
  • The American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA) offer these recommendations on steroid injections for joint pain in the context of the pandemic (8): 
    • Steroids increase potential for adrenal insufficiency and altered immune response 
    • Joints corticosteroid injection shown to be associated with higher risk of influenza 
    • Duration of immune suppression could be less with the use of dexamethasone and betamethasone
    • Consider evaluating risks/benefits of steroid injections and use a decreased dose, especially in high-risk patient populations
  • The Spine Intervention Society recommends: “Corticosteroid injections may contribute to immunosuppression and increased influenza risk. However, no study has yet been published that examines whether or not a corticosteroid injection increases the risk of contracting COVID-19 or alters the course of a subsequent infection. If used, consider reducing the dose of steroids (9)”

III.   Resources for Providers

The Journal of Radiology Nursing provides an article that summarizes precautions for steroid injections and includes a sample informed consent page for patients undergoing epidural corticosteroid injection (10)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Bone & Joint Open [Internet]. Bone & Joint Open. 2020 [cited 2020 Aug 5]. Available from: https://online.boneandjoint.org.uk/doi/full/10.1302/2046-3758.16.BJO-2020-0050.R1
  2. Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD, et al. A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. New England Journal of Medicine [Internet]. 2014 Jul 3 [cited 2020 Aug 5];371(1):11–21. Available from: https://www.nejm.org/doi/full/10.1056/nejmoa1313265
  3. Youssef J, Novosad SA, Winthrop KL. Infection Risk and Safety of Corticosteroid Use. Rheumatic Disease Clinics of North America [Internet]. 2016 Feb [cited 2020 Aug 5];42(1):157–76. Available from: https://pubmed.ncbi.nlm.nih.gov/26611557/
  4. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet [Internet]. 2020 Feb [cited 2020 Aug 5];395(10223):497–506. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext?fbclid=IwAR18JG3cpHvWPVa9ZOZ9ZZnUS1hVjQJ0A2KcTcRAp0z9I12TbIv8rUC4sv0
  5. Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. The Lancet [Internet]. 2020 Feb [cited 2020 Aug 5];395(10223):473–5. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30317-2/fulltext
  6. Sytsma TT, Greenlund LK, Greenlund LS. Joint Corticosteroid Injection Associated With Increased Influenza Risk. Mayo Clinic Proceedings: Innovations, Quality & Outcomes [Internet]. 2018 Jun [cited 2020 Aug 5];2(2):194–8. Available from: https://www.sciencedirect.com/science/article/pii/S2542454818300055
  7. National Health Service. Management of patients with musculoskeletal and rheumatic conditions on corticosteroids [Internet]. 2020 June [cited 2020 Aug 5]. Available from: https://www.rheumatology.org.uk/Portals/0/Documents/COVID-19/MSK_rheumatology_corticosteroid_guidance.pdf
  8. American Society of Regional Anesthesia and Pain Medicine. Recommendations on Chronic Pain Practice during the COVID-19 Pandemic [Internet]. Asra.com. 2020 [cited 2020 Aug 5]. Available from: https://www.asra.com/page/2903/recommendations-on-chronic-pain-practice-during-the-covid-19-pandemic
  9. Spine Intervention Society – COVID-19 Resources [Internet]. Spineintervention.org. 2020 [cited 2020 Aug 5]. Available from: https://www.spineintervention.org/page/COVID-19
  10. Hackett BA. Providing Steroid/Corticosteroid Injections Safely in the COVID-19 Environment. Journal of Radiology Nursing [Internet]. 2020 May [cited 2020 Aug 5]; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196431/

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.