Drug

• Methylprednisolone acetate (Depo-Medrol®)


• Triamcinolone hexacetonide (Aristospan®)

Dosage used in clinical practice

• 10 to 80 mg ia prn (depending on formulation used and size of joint)

Dosage according to CPS

• Depo-Medrol® (methylprednisolone acetate)
  • Large joints, e.g., knees, ankles, shoulders: 20 to 80 mg
  • Medium joints, e.g., elbows, wrists: 10 to 40 mg
  • Small joints, e.g., metacarpophalangeal, interphalangeal, sternocalvicular, acromioclavicular: 4 to 10 mg

• Aristospan® (triamcinolone hexacetonide)
  • Large joints, e.g., knee, hip, shoulder: 10 to 20 mg
  • Small joints, e.g., interphalangeal, metacarpophalangeal:
    2 to 6 mg

Indications

• Regional pain syndromes
• Degenerative joint disease (osteoarthritis [OA])
• Gout
• Pseudogout
• Rheumatoid arthritis [RA]
• Seronegative arthritis

Comments
Cortisone injections in a joint or a bursa are a good approach to treating local inflammation (RA, gout attack, OA flare) when NSAIDs are ineffective or contraindicated.

Joint injections minimize risks associated with systemic corticosteroid therapy and ensure that the medication is applied directly to the active site of the disease.

Indications for local injections are:

• Only one or a few joints inflamed
• The prevention of deformity and to assist in rehabilitation
• Relief of OA pain when there is evidence of local inflammation
• Soft tissue regional disorders.

The most common complication following an injection is an increase in pain along with signs of inflammation. This should not be viewed as an “allergy” to cortisone as it likely represents a local response to the cortisone “crystal” and usually diminishes within 24 hours with rest, analgesia and cold packs.

Cortisone injections in large joints (hips and knees) of individuals with inflammatory arthritis, e.g., RA, rheumatoid arthritis, may delay joint damage and time to total joint replacement. ¹

Large weight-bearing joints that are almost normal should only be injected occasionally (no more than three times a year). Those with established arthritis who have limited therapeutic options can receive injections more frequently.

Cortisone should never be injected if the diagnosis is unclear or if infection is suspected.

Local skin reaction is possible at the site of injection.

¹Roberts WN, Babcock EA, Breitbach SA et al. Corticosteroid injection in rheumatoid arthritis does not increase rate of total joint arthroplasty. J Rheum 1996;23:1001-1004.