A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders

The appeal of intra-articular corticosteroid therapy has increased with the growing emphasis on early disease control in rheumatoid disease. The impact on the patient's pain and stiffness is impressive and prompt. This may encourage patient compliance with longer term therapies given to slow the course of the disease. The release of corticosteroid into the circulation also provides some generalised improvement. This can prove helpful during the management of flares of inflammatory disease. There is less evidence to support the use of intra-articular corticosteroids in other inflammatory arthritides, but experience suggests that the benefits are similar. In osteoarthritis the benefits are less certain, but intra-articular therapy may prove important in patients who cannot undergo salvage operative procedures because of intercurrent illness. The benefits of intra-articular corticosteroids may be enhanced by rest after the injection, or by the additional administration of agents such as radio-colloids, rifampicin (rifampin), or osmic acid. Most controlled trial data have been published on knee injections, but other joints can be useful targets for local therapy. The risks are mainly related to the discomfort of the procedure, localised pain post-injection and flushing, but most feared is septic arthritis which probably occurs in about 1 in 10000 injections. Careful aseptic technique is the best protection. Tissue atrophy at the injection site, abnormal uterine bleeding, hypertension and hyperglycaemia rarely cause problems. Osteonecrosis might be as much a problem with uncontrolled painful arthritis as with a joint rendered less symptomatic by corticosteroid injections. Intra-articular corticosteroids form an important part of the management of inflammatory joint disease and might be considered where an inflammatory element occurs in osteoarthritis. They may be used at any stage in the arthritic process, but should be seen as an adjunct to other forms of symptom relief. In patients needing multiple joint injections, systemic therapy should be reviewed to see if better disease control could reduce the need for invasive therapy.