Intraarticular Corticosteroid Injections

Medication Considerations

• Intraarticular corticosteroid injections do not carry the same renal concerns as NSAIDs, which should be avoided in patients with eGFR <30 ml/min per 1.73 m², as noted by the VA/DoD guidelines 1

Technique and Administration

• Image guidance should be used for hip injections, as recommended by the VA/DoD guidelines 1
• Corticosteroid injection should be avoided within 3 months prior to planned joint replacement surgery, according to the VA/DoD guidelines 1
• Injection therapy is recommended for osteoarthritis, particularly for acute exacerbation of knee pain with effusion, and as a first-line option for acute gout flares, by the European League Against Rheumatism 2
• The American College of Rheumatology suggests considering injection therapy for rheumatoid arthritis when one or few residual active joints remain despite systemic therapy, and recommends ensuring appropriate diagnosis and ruling out contraindications before injecting for acute swelling 2, 3

Patient Selection and Preparation

• Patients can expect pain relief to last typically weeks to months, with potential for functional improvement, and possibility of needing repeat injections 2
• Patients should be informed about potential benefits, risks, and expected outcomes before proceeding with the intra-articular injection, using plain language and visual aids to ensure comprehension, as recommended by the American College of Rheumatology 2
• Diabetic patients should be warned about the risk of transient hyperglycemia for 1-3 days post-injection and the need to monitor glucose levels 2
• Patients on anticoagulants should be informed that injection is generally not contraindicated unless bleeding risk is exceptionally high 2
• Pregnant patients should be informed about safety considerations for mother and baby 2
• Patients planning joint replacement should be informed that injection should be performed at least 3 months prior to surgery 2
• Poorly controlled diabetes and prosthetic joint are relative contraindications for injection therapy, requiring careful consideration and consultation with the surgical team 2

Procedure and Follow-up

• Intra-articular injections should be performed with strict aseptic technique, including the use of surgical gloves, skin preparation with alcohol, iodine disinfectant, or chlorhexidine, and changing needles between drawing medication and injecting, as recommended by the American College of Rheumatology 2
• The procedure should be performed in a professional, clean, well-lit, private room with the patient positioned appropriately on an examination table, and equipment for aseptic procedures and resuscitation equipment readily available 2
• Consider offering local anesthetic with the injection to reduce procedure discomfort and explain pros and cons to the patient before administration 2
• Patients should avoid overuse of injected joints for 24 hours following intra-articular therapy, but complete immobilization is discouraged and normal activity is recommended 2
• Local pain at the injection site is common and typically resolves within 24-48 hours, patients may use ice for comfort if needed 2
• Instruct patients to seek medical attention if they experience severe pain that worsens after 48 hours, increasing redness, warmth, or swelling around the injection site, fever or chills, or drainage from the injection site 2
• A 30-day follow-up is appropriate to evaluate treatment response, assess for any adverse effects, and determine if additional interventions are needed, considering benefits from previous injections, individual factors, and planning for joint replacement surgery, if applicable 2
• Although not evidence-based, a generally accepted rule is to avoid more than 3-4 glucocorticoid injections in the same joint per year 2
• Infection risk, although rare (0.035%), is a serious complication, and always maintain strict aseptic technique to minimize this risk 2