Mod 7: Corticosteroids: Pharmacological properties, Adverse effects, Arthrocentesis, and injection therapy Flashcards
What is a Hormone?
Hormones are chemicals secreted by a cell or group of cells into the blood for transport to a distant target where it exerts an effect at very low concentrations
What are Steroids?
Naturally occurring homones synthesized mainly in the adrenal cortex (adrenal corticosteroids) and the gonads (sex steroids)
Adrenal glands are divided into 2 mophologically distinct regions, which are?
1.Adrenal Cortex (outer)
Zona glomerulosa (secretes aldosterone)
Zona fasiculata (secretes glucocorticoids)
Zona reticularis (secretes androgens)
2.Adrenal Medulla (inner)
Secretes epinephrine and norepinephrine
Adrenal Corticosteroids share a chemical structure and are derived from what?
Cholesterol
What affects carbohydrate, lipid, and protein metabolism also affects CV and nervous syustems and has anti-inflammatory and immunosuppressant actions?
GLUCOCORTICOIDS
What affects water and electrolyte balance by facilitating sodium re absorption and hydrogen and potassium excretion
MINERALOCORTICOIDS
Stimulating or controlling the maintenance of male characteristics via Testosterone and precursor to all Estrogens is what?
ADRENAL ANDROGENS
The most commonly used injectible corticosteroids are synthetic analogues of what?
CORTISOL
What actions do Glucocorticoids have on inflammation?
Inhibit synthesis of phospholipase A2-protein by inducing lipocortins resulting in mediating inflammation
What effect do Glucocorticoids have on Carbohydrate and Protein metabolism?
- Decrease peripheral utilization of glucose
- Increased glycogenisis (glucose from non-carbohydrate carbon substates such as lactate, glycerol)
- Increased glycogen deposition in the liver
- Overall -ve nitrogen balance and hypoglycemia
What effect do Glucocorticoids have on Lipid metabolism?
1.Fat redistribution (hump, moon face)
2.Promote adipokinetic agent activity:
glucagon, growth hormone, adrenaline, thyroxine.
What effect do Glucocorticoids have on Electrolyte and water balance?
- Increased aldersterone activity is most important.
2. Increased Na+ reabsorpsion and secretion of K+ and Hydrogen
What effect do Glucocorticoids have on the CV system?
- Restrict capillary permiability
- Maintain tone of arterioles (overall hypotension results)
- Myocardial contractility increased
- Mineralocorticoid induced hypotension
- Sensitized blood vessels to the actions of cathecolamines and angiotensin
What effect do Glucocorticoids have on Skeletal muscles?
- Needed for maintaining normal function of skeletal muscles.
- Prolonged elevated levels can lead to steroid myopathy.
What effect do Glucocorticoids have on GI?
Aggrivated Peptic ulcerations: Increased acid and pepsin secretion.
decreased immune response to H. Pylori.
Glucocorticoids have a direct and indirect effect on the CNS, how?
Direct: Mood, Behaviour, Brain excitibility
Indirect: Maintain glucose, circulation and electrolye balance.
May lead to intercranial pressures
What effect do Glucocorticoids have on Red Blood cells?
- Increased Hb and RBC content
2. Decrease erythrophagocytosis
What effect do Glucocorticoids have on White Blood Cells?
- Decrease levels of lymphocytes, esinophils, monocytes, basophils
What EFFECT do Glucocorticoids have on Inflammation?
- Decrease WBC recruitment and monocytes/macrophages into affected area and decrease function of chemotatic substances
- Increase lipocortin
- Decrease TNF (tissue necrosis factor)
- Decrease function of monocytes and macrophages
- Decrease formation of plasminogen activator
- Decreased fibroblastic activity
- Decreased expression of cyclooxygenase II
What effect do Glucocorticoids have on Immunosuppression?
- Suppresses all types of hypersensitivity and allergic phenomenon.
- Immunological response interference at high doses.
- Greater suppression of cell mediated immunity
Whether mechanical, infectious, chemical radiant, or immunological Glucocorticoids inhibit and prevent early anti-inflammatory/immunosupressive responses by inhibiting what?
- Edema
- Fibrin deposits
- Capillary dilation
- Migration of leukocytes
- Phagocytic activity
- Proliferation of capillaries and fibroblasts
- Deposition of collagen
What effect do Glucocorticoids have on Respiratory System?
- Not bronchodilator
- Potent/effective anti-inflammatory agent
- Effect not immediate (6 hour onset)
- Used for long term Rx of inflammation (asthma)
What effect do Glucocorticoids have on Cell growth and division?
- Inhibit cell division or synthesis of DNA
- Delay process of healing
- Retard the growth of children
What effect do Glucocorticoids have on Calcium metabolism?
- Decrease intestinal calcium absorption.
- Increased renal calcium excretion
- XS loss of calcium from spongy bones. (Vertibrae, ribs, femoral head)
What is the rational for Glucocorticoid use?
Reduce pain/inflammation
Break apart scar tissue and adhesions
List the potential immediate side effects of Glucocorticoid use.
Facial Flushing
Impaired Diabetic control (blood sugars may rise modestly for upto 1 week)
Menstrual Irregularity: may occur in pre/post menopausal women
Hypothalmic-pituitary axis suppression, but due to doses no precausions necc.
Drop in ESR and CRP levels
Anaphylaxis
Sepsis
Facial flushing can occur in 1-5% of cases, but what is onset and how long can it last?
Onset: can be 24-48 hours
Duration: several days
What are the clinical signs and symptoms of infection following a steroid injection?
Swelling at injection site
Increased pain
Fever
Dysfunction of affected part
The most common organisms identified in infections following a steroid injection are?
Staphlycoccus Aureus
Streptococci species
What are the potential risk factors for infection following steroid injection?
Prosthetic Joint Diabetes Oral steroid therapy Cytotoxic drug therapy HIV
Glucocorticoids carry potential systemic side effects with long term use, list them?
XS fat on abdomen Thinning Skin Thin arms and legs due to muscle atrophy Hypotension Intercranial pressure Buffalo hump Buise easily Avascular necrosis of femoral head Moon face Obesity Osteoporosis
List potential Local side effects of Glucocorticoid injection.
Post injection flare (2-10%) SubQ atrophy/skin depigmentation (1%) Bleeding/bruising Steroid 'chalk' or 'paste' (20-40%) Soft tissue calcification (10-20%) Steroid arthropathy Tendon atrophy/rupture (<1%) Sepsis (0.2-0.5%) Nerve damage Needle Fx Delay of soft tissue or bone healing
Corticosteroid use is absolutely contraindicated when?
Hx of hypersensitivity to any constituant agents If Hx of hypersensitivity to LA steroid may be given alone Sepsis (local, remote, systemic) Viral infection Fx site (can delay healing) Prosthetic joint (risk of infection) unstable joint Prenancy/Breast feeding Child <18 Consent not understood Pt reluctance in injection or aftercare
Relative contraindications to corticosteroid injections would include?
Diabetes (increased risk of sepsis, blood sugar) Immunosuppressed pts (HIV, Leukemia) High stress tendons Lack of response after 2 injections Bleeding abnormalities/anticoagulation Competitve Athlete (check with coach)
Generally how many site specific Injections is a patient allowed in a given year?
No more than 3
Short acting preparations include?
Hydrocortisone
Cortisone
Intermediate acting preparations include?
Prednisone
Triamcinalone Acetonide (kenalog)
Dexamethasone Sodium Phosphate (decadron)
Methylprednisone acetate (depo-medrol)
Long acting preparations include?
Dexamethasone Sodium Acetate (dexasone)
Bethamethasone (celestone)
What is the relative potency of Hydrocortisone and what is its equivalent dosage?
Potency - 1
Dosage - 20mg
What is the relative potency of Cortisone and what is its equivalent dosage?
Potency - 0.8
Dosage - 25mg
What is the relative potency of Prednisone and what is its equivalent dosage?
Potency - 3.5
Dosage - 5mg
What is the relative potency of Triamcinalone Acetonide (kenalog) and what is its equivalent dosage?
Potency - 5
Dosage - 4mg
What is the relative potency of Dexamethasone Sodium Phosphate (decadron) and what is its equivalent dosage?
Potency - 30
Dosage - 0.6mg
What is the relative potency of Methylprednisone Acetate (depo-medrol) and what is its equivalent dosage?
Potency - 5
Dosage 4mg
What is the relative potency of Dexamethasone Sodium Acetate (dexasone) and what is its equivalent dosage?
Potency - 30
Dosage - 0.6mg
What is the relative potency of Bethamethasone and what is its equivalent dosage?
Potency - 25
Dosage - 0.75mg
When using Glucocorticoids the minimum effective dosage should be used, TRUE or FALSE?
TRUE
Glucocorticoids Phosphates are relatively soluble, but how does this effect onset and duration of action?
Onset - 24-48 hours
Duration of Action - 1-2 weeks
Glucocorticoids Acetates have poor solubility, but how does this effect onset and duration of action?
Onset - 7-10 days
Duration - 4-6 weeks
Common ‘recipes’ of Glucocorticoids and LA for MPJ would include?
10-20mg Kenalog in 0.5-1cc of LA
3mg Celestone Soluspan in 0.5-1cc of LA
Common ‘recipes’ of Glucocorticoids and LA for Midtarsal joints would include?
10-30mg Kenalog in 0.5-1cc of LA
3-6mg Celestone Soluspan in 05-1cc of LA
Common ‘recipes’ of Glucocorticoids and LA for IPJ’s would include?
5-10mg Kenalog in 0.5-1cc of LA
1.5mg Celestone Soluspan in 0.5cc of LA
Common ‘recipes’ of Glucocorticoids and LA for AJ would include?
20-40mg Kenalog in 1-3cc of LA
6mg Celestone Soluspan in 1-3cc of LA
Common ‘recipes’ of Glucocorticoids and LA for Tendons would include?
10mg Kenalog in 0.5-1cc of LA
3mg Celestone Soluspan in 0.5-1cc of LA
Common ‘recipes’ of Glucocorticoids and LA for Heel would include?
20-40mg Kenalog in 1-3cc of LA
6mg Celestone Soluspan in 1-3cc of LA
In which articular conditions might a Glucocorticoid injection be considered?
Gout
Pseudogout
OA
Synovitis
In which nonarticular conditions might a Glucocorticoid injection be considered?
Plantar Fasciitis Bursitis Capsulitis Tendonitis/Tenosynovitis Tarsal Tunnel Syndrome Sesamoiditis Cyst Skin lessions/Scar tissue
Post injection flare occurs in 2-10% of patients and is what?
Most common following soft tissue injection than joint injection.
Temporary increase in pain
Possibly due to presence of parabens in multi use LA bottles
SubQ atrophy or skin depigmentation occurs in 1% of patients and is more likely to occur in superficial injections and dark pts, TRUE or FALSE?
TRUE
Steroid ‘chalk’ or ‘paste’ occurs in 20-40% of pts and is generally asymptomatic but how does this occur?
Develops in the tissues and may be a result of mixing steroid with LA containing preservative.
What % does Soft tissue calcification occur in pts following steroid injection?
10-20%
0.2-0.5% of pts suffer sepsis following steroid injection, what are the sign & symptoms?
Swelling at injection site
Fever
Increased pain
Dysfunction of affected part
When choosing Glucocorticoids agent and dose what is useful to keep in mind?
- Min dose should be administered
- Gluco. Phosphates are fast acting with short acting duration
- Gluco. Acetates are slow acting and long action duration
Heel Cortisone injection technique is?
Mixture of 1-3ml Xylocaine plain and Glucocorticoid of choice (0.5-1ml of celstone soluspan 6mg/ml or equivalent)
Select 25-27g needle (larger bore needles for acetate steroids due to larger crystals)
Following skin prep
Insert needle rapidly 90degrees to medial side of heel, distal to fat pad, near point of max tenderness, or dorsal to plantar fascia.
Avoid injecting plantar to Fascia due to risk of rat pad atrophy.
Apply band aid.
Intermetatarsal Cortisone injection technique is?
Mix of 0.5-1ml Xylocaine plaine and Glucocorticoid of choice.
Select 25-27g needle (larger bore needles for acetate steroids due to larger crystals)
Following skin prep
Needle is inserted perpendicularly just prox to met heads to depth of 1.5-2cm to below trans met lig, but NOT into fat pad
Apply band aid and give after care advise to pt.
B12 is sometimes applied to the solution when injecting around a symptomatic nerve, what is a suggested b12/steroid preparation?
1cc B12
1cc Xylocaine Plain
0.5cc Decadron 4mg/ml
Paratendon injection technique is?
0.5-1cc of Xylocaine and PHOSPHATE steroid solution (caution should be used when considering acetate solution due to longer duration of agent potentially weakening tendon)
Needle inserted perpendicular to skin then repositioned to place needle tip into tendon sheath (not tendon)
Apply band aid and pt after care.
Immobilization may be required for high load tendons.
Intradermal injection technique is?
Acetate glucocorticoid (eg dexasone 4mg/ml or equivalent) no need for LA needle is repetitively inserted into lesion with small droplets left behind
MPJ injection technique is?
0.5-1ml of xylocaine and glucocorticoid (eg 0.5-1ml of celestone soluspan 6mg/ml)
Needle is injected following skin prep into dorsomedial aspect of joint medial to extensor.
Insert needle 90 deg and passed until tip is ‘felt’ to have passed capsule.
reposition if bone is encountered.
apply band aid and after care.
STJ injection technique is?
1ml xylocaine plain and glucocorticoid of choice.
lateral aspect is preffered access inferior and posterior to tip of lat mall
pass needle 0.5-1 inch deep (into capsule) towards medial mall, reposition if bone is encountered.
apply band aid and after care advice.
AJ injection techinique is?
1-3ml of xylocaine plain, and glucocorticoid of choice
Inection site is midway between med mall and tib ant tendon
Advance needle to centre of joint 0.5-1 inch deep
apply band aid and after care advice.
General Corticosteroid after care is?
Band aid dressing to be kept on, dry and intact for 24-48 hours
Avoid excess weight-bearing 1-3 days
Gentle movement and light activities permitted
Short immobilization following high load tendon injection
Atherosentisis is what?
Also known as joint aspiration is the clinical procedure of using an ijection to obtain synovial fluid from within a joint capsule.
When is Atherosentisis useful?
can be used in the Dx of Gout, Arthritis, Infection or other joint abnormalities
If a joint effusion is present aspiration may be useful both Dx and theraputically, TRUE or FALSE.
TRUE
Should aspiration take place through a site of cutaneous infection, yes or no?
Yes, only if the joint is thought to be the cause of the cutaneous infection.
Atherosentisis needle should not pass through a psoriatic plaque because?
These are heavily colonized by bacteria.
What size needle is typically required for Atherosentisis?
18-19g due to viscosity and/or presence of debris.
After aspiration what should be examined?
Fluid extracted for colour, clarity, viscosity.
If required send syringe to lab without needle within 4 hours.
What are the most common tests for synovial fluid?
WBC count
Gram stain
Culture and sensitivity
presence or absence of crystals.
Non-inflammatory Synovial fluid has what characteristics?
Colour: yellow/straw WBC count: 200-2000 Clarity: transparent Neutrophil %: low Viscousity: high
Normal synovial fluid characteristics are?
Colour: Clear WBC count: 0-200 Clarity: transparent Neutrophil %: low Viscousity: high
Inflammatory synovial fluid characteristics are?
Colour: yellow WBC count: 2000-75000 Clarity: hazy/opaque Neutrophil %: med-high Viscousity: low
Septic Synovial fluid characteristics are?
Colour: variable WBC count: >50000 Clarity: opaque Neutrophil %:high Viscousity: low-high
Labels for types of aspirate encountered are?
Clear fluid streaked with fresh blood Uniformly bloody fluid Xanthochromatic fluid Turbid fluid Frank Pus Milky fluid
What is Clear synovial fluid streaked with fresh blood?
A common finding which relates to trauma of aspiration. rarely a blood vessel is damaged during aspiration, with draw needle and apply pressure for several minutes.
What is uniformly bloody synovial fluid?
Haemarthrosis, usually following Hx of trauma.
X-ray mandatory.
If lipid layer this suggest intra articular Fx.
Rarely this might be due to bleeding disorder or anticoagulation therapy.
What is xanthochromatic synovial fluid?
Old broken down blood - orange in colour
Hx of old trauma
What is turbid synovial fluid?
represents Inflammatory joint fluid
fluid is darker dur to presence of debris, cells and fibrin
corticosteroid is best deferred until microscopy and culture studies are available.
What is frank pus synovial fluid?
Foul smelling
Sepsis of joint
Pt requires admission due to being quite ill
What is milky synovial fluid?
May represent high cholestrol
or presence of crystals
