Doses Of Triamcinolone Research Articles

Modeling experimental glaucoma for screening studies of antiglaucomatous activity

Introduction: In vivo screening studies, in which the efficacy of dozens of drugs is tested to select several applicants for further study of their safety in humans, are the main stage in the study of the pharmacodynamics of promising antiglaucoma drugs. This imposes a number of specific requirements both on experimental models of glaucoma and on laboratory animals used in the experiment.
 Materials and Methods: 32 male rabbits of the Soviet Сhinchilla breed, 6 male albino rabbits weighing 3-3.5 kg, and 20 outbred white rats weighing 220-250 g were used in total in experiments to reproduce the glaucoma process. All manipulations on the rabbit eye were performed by an ophthalmologist under general anesthesia with telazol. Triamcinolone (vitreous injection) was used to simulate glaucoma in rabbits, lauromacrogol 400 or fine kaolin (anterior chamber injection) was used to simulate glaucoma in rabbits; adrenaline hydrochloride (intraperitoneal administration) was used to simulate glaucoma in rats.
 Results and Discussion: Double intravitreal administration of a suspension of triamcinolone at a dose of 4 mg was the most attractive model in terms of the technique of reproducing the pathology and the results obtained in modeling glaucoma in rabbits. However, this model did not produce a stable increase in intraocular pressure (IOP). Doubling the dose of triamcinolone and replacing chinchilla rabbits with albinos did not lead to a positive result. The introduction of the venous sclerosing drug lauromacrogol 400 into the anterior chamber of the eye proved to be ineffective either. The introduction of finely dispersed kaolin into the anterior chamber of the eye of rabbits led to a persistent increase in IOP. The intraperitoneal administration of epinephrine hydrochloride to rats according to the described method gave no stable results. The increase in IOP became stable only after a significant increase in the dose of adrenaline.
 Conclusion: The conducted studies of four models of glaucoma and their three modifications in animals made it possible to select two of them, which contributed to a stable and fairly long-term increase in IOP in rabbits (introduction of finely dispersed kaolin into the anterior chamber of the eye) and rats (adrenaline-induced model).

How safe are intra-articular corticosteroid injections to the hip?

BackgroundIntra-articular corticosteroid injections (ICSI) are an effective symptomatic treatment for osteoarthritis of the hip. However, the safety of ICSI has been questioned and a relatively high risk for septic arthritis, rapidly progressive osteoarthritis (RPIO) and periprosthetic joint infections (PJI) in patients undergoing subsequent total hip arthroplasty (THA) have been suggested.MethodsThis is a retrospective evaluation of 682 hips that underwent ICSI with 40 mg of Triamcinolone for primary osteoarthritis of the hip. All ICSI were performed using sterile techniques, the number of ICSI in each hip and the cumulative corticosteroid dosage were assessed. Pre- and post-injection radiographs were compared to identify cases with RPIO. Native joint septic arthritis, surgical site infections and PJI were identified by chart review.Results4 hips (0.6%) developed RPIO 2–4 months following ICSI. The cumulative Triamcinolone dose was not associated with the development of RPIO (p = 0.281). 1 case was diagnosed with septic arthritis and treated with staged THA, there were no signs of infection at a 5 years follow-up. 483 hips (75.7%) underwent THA, including 199 hips with THA less than 3 months following ICSI and 181 hips with > 1 ICSI prior to THA. There were 3 superficial surgical site infections/wound dehiscence and no PJI.ConclusionThe rate of RPIO was 0.6%. The current findings suggest that if ICSI is performed under sterile conditions, the risk for septic arthritis or PJI following THA, even in patients with multiple ICSI or ICSI within 3 months prior to surgery, is minimal.

Short-Term Efficacy and Safety of the Direct Triamcinolone Application Using Absorbable Nasal Packing in Anosmic Patients

Background and Objectives The most common treatment for olfactory dysfunction is the use of glucocorticoids. However, using systemic glucocorticoids is limited due to systemic side effects, and topical glucocorticoids are less effective than systemic glucocorticoids. The aim of this study is to evaluate short-term therapeutic effects of direct triamcinolone (TA) application using absorbable nasal packing material on anosmia patients.Subjects and Method This was a retrospective study that evaluated patients who were diagnosed with anosmia and treated with oral prednisolone (PD) pulse therapy or 2 times of a 20 mg dose of TA impregnated absorbable nasal packing in both olfactory clefts. Information of the demographic features, the self-reporting olfaction scores (visual analogue scale [VAS], 0-10), and the threshold, discrimination, identification (TDI) scores of Korean version of the Sniffin’ stick test II were collected and analyzed.Results The data of 72 patients were analyzed in this study: 30 patients were treated with TA nasal packing, and 42 patients with oral PD. In both group, VAS and TDI scores were significantly improved 2 weeks after treatment. The rate of significant olfactory improvement of TA nasal packing group was higher than oral PD group (60.0% vs. 47.6%), but there was no statistically significant difference (<i>p</i>=0.300). There was no significant systemic adverse effect after TA nasal packing treatments.Conclusion Direct TA application using absorbable nasal packing is a possible treatment option in anosmic patients.

Effect of caudal epidural adhesiolysis plus steroid injections on pain and daily activities among chronic lumbar disc herniation patients; an observational study

Background & Objective: The management of lumbar disc herniation (LDH) remains a big challenge as it may involve the surrounding tissues, and attract neovascularization facilitated macrophage aggregates. Epidural triamcinolone might have a half-life action ranging from 10 to 31 days, whereas 80 mg methylprednisolone might improve the pain up to 1 week. The higher doses of steroids will lead to adrenal cortex suppression and osteopenia. We evaluated the effect of treatment with 1500 international unit (IU) hyaluronidase followed by 20 mg triamcinolone at 2 weeks, and 3 and 6 months follow-up.
 Methodology: We enrolled seven males (38.9%) and 11 females (61.1%) with mean age 44 ± 23 y in the study. Eight (44.44%) subjects were younger than 51 y old, whereas the 10 (55.56%) subjects were ≥ 51 y old. Twelve (66.7%) subjects had had a bulged disc, and 6 (33.3%) subjects had disc protrusion. We injected 1500 international unit (IU) hyaluronidase followed by 20 mg triamcinolone at the site of disc lesion. Pain scores were measured with NRS scale and Oswestry Disability Index (ODI) scores at 2 weeks, and 3- and 6-months follow-up.
 Results: The NRS score improved at 2 weeks, 40% to 71.43%, at 3 months 60% to 100%, and 6 months 80% to 100%. And the Oswestry Disability Index (ODI) score was improved at 2 weeks from 23.5% to 68.18%), at 3 months from 39.13% to 100%, and at 6 months 82.35% to 100%. A significant association was observed between age older than 50 y old and ODI scores at 2 weeks followed up.
 Conclusions: The intra-epidural 1500 IU hyaluronidase before triamcinolone brings better results even though using a lower dose of triamcinolone. This approach showed the lower-cost better pain scores as compared to the routine use of heavy doses of triamcinolone for managing bulged and protruding LDH.

Effect of Ropivacaine Combined with Small Doses of Triamcinolone and Continuous Nerve Block of Unilateral Paravertebral Canal Guided by Ultrasound on Metastasis after Radical Treatment of Lung Cancer

Continuous nerve block of unilateral paravertebral canal is one of the most reliable and the most commonly performed techniques to control intra- and postoperative pain. It is the technique of injecting local anaesthetic alongside the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramen. This produces unilateral, segmental, somatic, and sympathetic nerve blockade, which is effective for anaesthesia and in treating acute and chronic pain of unilateral origin from the chest and abdomen. Ultrasound guidance with or without nerve stimulator has reduced the amount of local anaesthetics (LA) to achieve a successful block, which may minimize complications of continuous nerve block of unilateral paravertebral canal. Previous studies have suggested that continuous nerve block of unilateral paravertebral canal with ropivacaine combined with small doses of triamcinolone was effective to achieve sensory and motor block after lung cancer surgery. Previous studies have used a fixed large dose in different volumes and concentrations for a nerve block, infraclavicular block, axillary block, and humeral canal block. The results of these studies with the respects of onset time, successful rate, and block duration were not consistent. Various factors, including the technique used, the anatomic aspects of the injection, and the pharmacodynamics aspect of drug, may influence the results. We tested the hypothesis that 50,25,10 mg ropivacaine and 50,25,10 mg triamcinolone of three combinations of volumes and concentrations for ultrasound-guided continuous nerve block of unilateral paravertebral canal produce different effects in the aspect of survival rate. Here, the drug effect was analyzed using the cross cluster K-nearest neighbors (KNN). The whole experimentation was carried out under MATLAB environment.

Weakness After an Intraarticular Steroid Injection: A Case Report of Acute Steroid-Induced Myopathy

Introduction: Weakness is a common chief complaint in the emergency department, and the use of glucocorticoids is pervasive in medicine. Muscle weakness, or myopathy, is a well documented side effect of chronic glucocorticoid use. However, acute myopathy, with an onset shortly after initiation of glucocorticoids, is much rarer. Case Report: We present a case of acute steroid-induced myopathy after a single intra-articular dose of triamcinolone in a young, healthy, active male. To our knowledge, this is the first case described in the medical literature of acute steroid-induced myopathy following a single intra-articular injection. Conclusion: In a patient who presents with proximal muscle weakness and has a history of glucocorticoid use, the diagnosis of steroid-induced myopathy should be considered. Acute steroid-induced myopathy should be high on the differential in a patient who presents with typical symptoms and has been prescribed glucocorticoids for less than 14 days or, in rare cases, may have recently received a single dose of glucocorticoids. Treatment is supportive and outpatient management is typically indicated, as respiratory muscle involvement is rare.

Weakness After an Intra-articular Steroid Injection: A Case Report of Acute Steroid-induced Myopathy.

IntroductionWeakness is a common chief complaint in the emergency department, and the use of glucocorticoids is pervasive in medicine. Muscle weakness, or myopathy, is a well documented side effect of chronic glucocorticoid use. However, acute myopathy, with an onset shortly after initiation of glucocorticoids, is much rarer.Case ReportWe present a case of acute steroid-induced myopathy after a single intra-articular dose of triamcinolone in a young, healthy, active male. To our knowledge, this is the first case described in the medical literature of acute steroid-induced myopathy following a single intra-articular injection.ConclusionIn a patient who presents with proximal muscle weakness and has a history of glucocorticoid use, the diagnosis of steroid-induced myopathy should be considered. Acute steroid-induced myopathy should be high on the differential in a patient who presents with typical symptoms and has been prescribed glucocorticoids for less than 14 days or, in rare cases, may have recently received a single dose of glucocorticoids. Treatment is supportive and outpatient management is typically indicated, as respiratory muscle involvement is rare.

HYLAN G-F 20 VERSUS TRIAMCINOLONE IN THE TREATMENT OF PRIMARY SHOULDER OSTEOARTHRITIS. RANDOMIZED TRIAL.

ABSTRACTIntroduction The aim of this study was to evaluate the effect of using an intra-articular injection of hylan G-F 20 (HA group) on primary shoulder osteoarthritis compared with an intra-articular triamcinolone injection (T group).Materials and Methods The patients were randomized into 2 groups: in the HA group a single dose of intra-articular hylan G-F 20 was administered and in the T control group a dose of triamcinolone 20 mg was administered. The participants were evaluated at 1 week, 1, 3, and 6 months after the procedure. The patients were evaluated for pain, range of motion, Constant score, modified UCLA score, and SPADI.Results Seventy patients met the inclusion criteria and were randomized to the HA (38) and T (32) groups. Improvements in range of motion were significant (p > 0.05). We observed decreases in the general visual analog scale (VAS) for pain in both groups, especially in the cases of mild and moderate arthritis that received hyaluronic acid (mean values from 8.1 initially to 4.9 after 6 months) (p = 0).Conclusions Both injections led to a decrease in pain and an increase in patient satisfaction. The results tend to be better and longer lasting in patients receiving hyaluronic acid. Level of evidence II b; Cohort study.

Efficacy of Intra-Articular Injection of 10 mg and 20 mg Triamcinolone for Rheumatoid Arthritis of the Wrist: A Prospective, Randomized, Pilot Study.

Background: To compare the efficacy of intra-articular injection (IA) with 10 mg and 20 mg triamcinolone for treatment of rheumatoid arthritis (RA) of the wrist joint. Methods: We enrolled 20 patients with swelling and pain in wrist due to RA in the present prospective, randomized, pilot study. Patients were randomly assigned in a 1:1 ratio to either the 20 mg or 10 mg group, and received IA of the appropriate dose of triamcinolone. Efficacy was assessed by recording Numerical Rating Scale (NRS) for pain and improvement in power doppler (PD) scale score at weeks 1, 4, and 12 of treatment compared with baseline. The shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) was recorded at baseline and week 12. Results: The NRS was found to be significantly improved at weeks 4 (p = 0.006) and 12 (p = 0.036) among the total study population. Neither the change in NRS nor the improvement PD scale score from baseline were significantly different between the two groups at any week (NRS: week 1, p = 0.617; week 4, p = 0.727; and week 12, p = 0.878; PD scale score: week 1, p = 0.370; week 4, p = 1.000; and week 12, p = 0.179). Among the entire study population, the QuickDASH was not significantly improved at week 12 nor was the change from baseline significantly different between the two groups at week 12 (p = 0.592). Conclusions: IA of triamcinolone was effective for pain relief in context of RA in the wrist joint. However, in terms of NRS, improvement of PD scale score, and QuickDASH score, the efficacies of 10 mg and 20 mg triamcinolone were not significantly different. Thus, IA of 10 mg triamcinolone may be sufficient for the treatment of RA in the wrist joint.

A COMPARATIVE STUDY OF INTRALESIONAL TRIAMCINOLONE ACETONIDE ALONE VERSUS COMBINATION OF 5-FLUOROURACIL AND TRIAMCINOLONE ACETONIDE IN THE TREATMENT OF KELOID

Background: Keloids are benign proliferative condition of dermal broblast. Intralesional corticosteroid improves keloid but associated with signicant adverse effects like dyspigmentation, tissue atrophy and telengectasia and contraindicated in certain conditions like hypertension and diabetes. 5-Fluorouracil (5-FU), a pyrimidine analogue with an inhibitory effect on TGF-β induced broblast proliferation is useful in treatment of keloids but is associated with ulceration and pain. A low dose of Triamcinolone if added to 5-FU injection overcomes these issues. Approach: This study was conducted in a tertiary care hospital. Sixty patients; thirty in each group were included. In group A, once weekly intralesional Triamcinolone and in group B, intralesional injection of Triamcinolone mixed with 5-Flurouracil in 1: 9 dilution were injected for 8 sessions. Parameters of Vancouver scale were noted at the baseline and at the end of treatment. Results: Out of 60 patients enrolled in this study. The combination group was better in improving height (62.11% vs 78%), pliability (44.14% vs 8.81%), and vascularity (55.78% vs 61.30%) and results were statistically signicant (P valve <0.05) however it was not better in improving pigmentation (43.47% vs 20%) and volume (69.79% vs 80.76%) (P valve > 0.05). Pain and pruritus improved completely (100%) in both the groups at the end of the treatment. Excellent improvement in patient and observer assessment score was seen in 96.67% vs 3.33% in combination group and TAC group respectively. The difference was statistically signicant (P valve<0.05). Combination was better irrespective of age of the patient, duration, site, and origin of keloid. All patients treated with 5 FU develop ulceration and pain. Conclusion: Both the therapies are effective but combination is superior to TAC alone. We advocate that 5-FU should be used alone, addition of TCA does not have any added advantage in therapeutic outcome rather it increases the cost of treatment.

Treatment of Auricular Pseudocyst with Intralesional Steroid: A Study with Short-Term Follow-Up.

IntroductionA pseudocyst is an uncommon, painless, benign cystic swelling on the lateral surface of the auricle with an unknown etiology. Various treatment modalities have been used with varying rates of success as this condition has high propensity for recurrence. We have used a minimally invasive treatment method for this condition to evaluate its efficacy in our setup.Patients and MethodsThis is a prospective study carried out in the department of ENT of Chitwan Medical College from May 2018 to April 2020. Complete aspiration of the pseudocyst with intralesional steroid (40 mg, triamcinolone acetonide) injection was done in 30 patients. They were followed up weekly for 4 weeks. Additional doses were injected in cases with persistence or recurrenqce before 3 weeks. Disappearance of the swelling, considered treatment success, was the main outcome. The total number of doses required for the complete resolution of the swelling along with the number of recurrences or complications, if any, were noted at the final follow-up at 4 weeks.ResultsAll of our patients responded completely with intralesional triamcinolone. However, the total dose requirement for different patients varied. Out of the 30 patients, 21 (70%) responded to the single dose of the drug. Six (20%) required a second dose, while the remaining 3 (10%) patients required a third dose for complete resolution of the swelling. All three (10%) patients who received a third dose of triamcinolone complained of skin thickening, but there was no obvious cosmetic deformity.ConclusionAspiration with intralesional steroid injection shows an immediate positive response in patients with auricular pseudocyst. It can achieve complete resolution of the swelling without any serious complications. Thus, it appears to be a simple and effective management of the condition in the short term.

SUN-188 Intra-Articular Triamcinolone Injections - a “Slipped” Cause of Cushing’s Syndrome

Background:Triamcinolone injections are used to treat various orthopedic and rheumatologic conditions; their effects on the hypothalamic pituitary adrenal axis have not been well characterized.Clinical Case:A 14 yo female was referred to our clinic for evaluation of low TSH (0.16 µIU/mL) and possible hyperthyroidism. There was no goiter and she appeared euthyroid and had normal free T4 (1.01 ng/dl) but she had typical features of Cushing syndrome (CS), including round facies, thinning of hair, fatigue, truncal adiposity, violaceous striae, facial hirsutism and oligomenorrhea. She was previously healthy and participated in many sports. She did not report any history of exogenous glucocorticoid use but the fasting ACTH (4 pg/ml) and cortisol (0.1 µg/dl) levels were suppressed. Subsequent chart review revealed that she received intra-articular Triamcinolone (TA) to treat “slipping rib” syndrome. This included 3 injections of Kenalog 40 mg/mL, the last in July 2019. Her cumulative TA dose was 440 mg, the equivalent of prednisone 550 mg. Triamcinolone acetonide 1.4 mcg/dL (normal 0-0.1, analyzed by LC-MS/MS) was detected in the urine over 3 months after her last injection.Conclusion:- Levels of ACTH and cortisol can be suppressed for several months after intra-articular corticosteroid injections, placing the patient at subsequent risk for adrenal crisis- In some cases, high doses of Triamcinolone administered by intra-articular injection can cause clinical Cushing syndrome

Comparison between fractional Co2 laser-triamcinolone injection combination therapy and triamcinolone injection monotherapy for keloid

The histopathologic view of keloid shows dense fibroblasts and bundles of collagen throughout dermis. Treatment that completely cure keloid still not exist, although there are many treatment options. The monotherapy fractional CO2 laser shows good results, but is still as an adjuvant therapy. Fractional CO2 laser affects fibroblast and its functions in producing collagen. The combination therapy will combine the selective phototermolysis effect of CO2 lasers with antimitotic and antiinflammatory effects of corticosteroids. This study was an open trial with parallel design that compared fractional CO2 laser-intralesional triamcinolone acetonide combination therapy (treatment group) and intralesional triamcinolone acetonide (control group) in keloid patients with collagen density as evaluation parameter. The dose of triamcinolone was 10 mg/ml of 0.05-0.1 ml/cm2 of keloid. Fractional CO2 laser energy setting was 10-20 mJ. The decrease of collagen density in control and treatment group was significant (p=0.008 and p=0.001), although the decrease difference between control and treatment group was not significant (p=0.328). The collagen density that decrease in a shorter time shows that fractional CO2 laser could be a good combination therapy.

Corticosteroid Injections for Adhesive Capsulitis: A Review.

Adhesive capsulitis is a self-limiting condition in a majority of patients and is often treated nonoperatively. However, symptoms may take 2 to 3 years to resolve fully. A small, but significant, portion of patients require surgical intervention. The purpose of this systematic review is to evaluate the efficacy of corticosteroid injections for the treatment of adhesive capsulitis (AC). A review of articles indexed by the United States National Library of Medicine was conducted by querying the PubMed database for studies involving participants with AC, frozen shoulder, stiff shoulder, or painful shoulder. Articles that included corticosteroids, glucocorticoids, steroids, and injections were included. Corticosteroid injections provide significant symptom relief for 2 to 24 weeks. Injections can be performed intra-articularly or into the subacromial space. Evidence suggests that a 20 mg dose of triamcinolone may be as effective as a 40 mg injection. It remains unclear whether image-guided injections produce a clinically significant difference in outcomes when compared with landmark-guided (blind) injections. Corticosteroids may be less beneficial for diabetic patients. Patients using protease inhibitors (antiretroviral therapy) should not receive triamcinolone because the drug-drug interaction may result in iatrogenic Cushing syndrome. Corticosteroid injections for AC demonstrate short-term efficacy, but may not provide a long-term benefit. More high quality, prospective studies are needed to determine whether corticosteroid injections using ultrasound guidance significantly improve outcomes.

Evidence of invasive and noninvasive treatment modalities for hypertrophic scars: A systematic review.

Currently, there are various therapeutic approaches to reduce hypertrophic scarring; however, there is no standard evidence-based treatment protocol. Hence, a systematic review was performed to obtain a summary of the latest clinical trials to evaluate evidence for the treatment of hypertrophic scars. The review protocol was registered and approved by PROSPERO (CRD42015027040). PubMed and Web of Science were searched using predefined MeSH-Terms to identify studies published within the last 10 years regarding treatment for hypertrophic scars. Exclusion criteria included a level of evidence (LoE) lower than I, nonhuman in vivo studies, in vitro studies, studies on keloids, literature reviews, and non-English articles. The literature search identified 1,029 unique articles, whereas 6 articles were prospective, randomized, blinded, controlled clinical trials with a LoE I, and were thus included in the systematic analysis. Three clinical trials evaluated silicone products and pressure garments, and the other three studies investigated the efficacy of intralesional injections of triamcinolone (TAC), 5-Fluorouracil (5-FU) combined with TAC as well as the additional irradiation with a 585 nm pulsed-dye laser (PDL). Intralesional injections revealed significant improvements of the scar quality in terms of height, thickness, erythema, and pigmentation. Pressure garments showed favorable results but there was no evidence that silicone products were able to improve the scar quality. The systematic review demonstrated that there are just a few clinical trials with a LoE of I. Consequently, evidence is still lacking especially for noninvasive treatment regimens for hypertrophic scars. Intralesional injections of 5-FU mixed with a low dose of TAC can be seen as most appropriate treatment modality. Prospective clinical trials to determine the efficiency of silicone products are warranted.

Clinical and radiographic outcome of a treat-to-target strategy using methotrexate and intra-articular glucocorticoids with or without adalimumab induction: a 2-year investigator-initiated, double-blinded, randomised, controlled trial (OPERA)

ObjectivesTo study clinical and radiographic outcomes after withdrawing 1 year's adalimumab induction therapy for early rheumatoid arthritis (eRA) added to a methotrexate and intra-articular triamcinolone hexacetonide treat-to-target strategy (NCT00660647).MethodsDisease-modifying antirheumatic...

Prevention of esophageal stenosis after large endoscopic submucosal dissection: is there a better way to use steroids?

Prevention of esophageal stenosis after large endoscopic submucosal dissection: is there a better way to use steroids?

Relationship between Bone Mineral Density and the Frequent Administration of Epidural Steroid Injections in Postmenopausal Women with Low Back Pain

Epidural steroid injection (ESI) is one of the most common nonsurgical treatments for low back pain. In general, corticosteroid therapy often results in bone loss and osteoporosis. In previous studies, bone mineral density (BMD) was evaluated after epidural injections of relatively small numbers and relatively low total doses of corticosteroids. However, the relationship between BMD and multiple ESIs remains to be elucidated. To explore the relationship between BMD and multiple ESIs in postmenopausal women with low back pain. Medical records of postmenopausal women with low back pain treated with or without ESIs were reviewed. BMD was measured in the lumbar spine, femoral neck and total femur after the treatments. A total of 71 patients were divided into two groups: group 1 included patients who had received non-ESI medications; and group 2 included those who had received ESIs >10 times, with a cumulative administered triamcinolone dose >200 mg. Patients in group 2 showed lower BMD in the femoral neck and total femur. However, no significant intergroup differences in the BMD of the lumbar spine were observed. The prevalences of osteoporosis and osteopenia in the lumbar spine and femoral neck were significantly higher in group 2; these patients also had lower femoral neck BMD Z-scores. Multiple ESIs (approximately 14 injections with a cumulative triamcinolone dose of approximately 400 mg) can reduce BMD in postmenopausal women with low back pain.

Cushing Syndrome and Giant Sterile Abscess Induced by Self Intramuscular Injection of Supra-therapeutic Doses of Triamcinolone

Corticosteroid are among the most commonly used medications for a wide range of inflammatory, autoimmune and neoplastic disorders. Therefore, it is important for the physician to be aware of their side effects, in relation to different forms and delivery, that occur more often with oral therapy. A 33-year old professional drummer had been suffering from bilateral tenosynovitis of the wrists for three months. In order to accelerate the recovery and play drums again, he self-injected supra-therapeutic doses of triamcinolone acetonide (a total of injected drug > 2,400 mg was calculated) in his right gluteus. The intramuscular overuse of triamcinolone acetonide caused Cushing syndrome associated with a giant sterile abscess that involved the right gluteal muscles and the adjacent subcutaneous tissue. A large intramuscular sterile abscess can be a side effect of supra-therapeutic intramuscular triamcinolone dose and this should be explained to the patient prior to initiation of treatment with triamcinolone.

Effects of Two Different Doses of Epidural Steroid on Blood Glucose Levels and Pain Control in Patients with Diabetes Mellitus

Background: A high incidence of diabetes mellitus has been reported among patients diagnosed with lumbar degenerative spinal diseases. Although epidural steroid injections are known to increase the postprocedure blood glucose level, it has not been investigated whether a lower steroid dose can reduce blood glucose excursions and still be effective in controlling patients’ subjective pain. Objective: We compared the effects of 2 common doses of triamcinolone administered via epidural steroid injections on blood glucose levels and pain control in patients with diabetes mellitus to determine an adequate epidural steroid dose. Study Design: A prospective observational study. Methods: One hundred patients with diabetes mellitus were enrolled. They received lumbar transforaminal, lumbar interlaminar, or caudal epidural triamcinolone for radiculopathy, spinal stenosis, or failed back surgery syndrome. After the type of procedure was clinically determined, the doses of triamcinolone given were randomly chosen, either 40 mg (Group 40) or 20 mg (Group 20). The patients were asked to measure their finger stick blood glucose level twice daily (fasting and postprandial) for 3 days before the injection, on the day of the injection, for 7 days after the injection, and at 14 days after the injection. They also kept a blood glucose diary. Employment status and clinical outcome were evaluated at 8 weeks after the procedure. Results: There were significant increases in fasting blood glucose (FBG) level on postprocedure day (PPD) #1 to PPD #3 in Group 40, but on PPD #1 in Group 20. Moreover, there was a significant difference in FBG between groups on PPD #1 and PPD #2 (FBG on PPD #1: 179 [51]) mg/dL in Group 40 versus 146 [50] mg/dL in Group 20, P < 0.001]. Postprandial blood glucose (PBG) level was significantly elevated in both groups from PPD #0 to PPD #3. Notably, the increase in PBG was significantly greater in Group 40 than Group 20 on PPD #0 and #1 (PBG on PPD #0: 288 [57] mg/dL versus 242 [94] mg/dL in Groups 40 and 20, respectively, P = 0.004). The numeric rating scale for pain reported by the patients decreased for 2 weeks after treatment with no difference between groups. Employment status and clinical outcome was not different between groups. Limitations: The patients who chose to participate in this study may be a cohort of well-controlled patients with diabetes mellitus. The type of procedure performed was determined by a clinical decision and not randomized. The different routes of administration and diagnosis of failed back surgery syndrome can result in different levels of systemic absorption, thereby influencing the degree and duration of hyperglycemia. In patients with FBSS, the epidural space may be destructed by surgery and adhesive changes in epidural space could be extensive. Therefore, we thought that the absorption of epidural space in these patients would be incomplete or slow compared with those without FBSS. Conclusion: Epidural steroid injections were associated with statistically significant elevations in PBG in patients with diabetes for up to 4 days after the procedure. The higher dose of triamcinolone increased FBG and PBG greater than a lower dose did without affecting pain control, employment status, or clinical outcome. Thus, with respect to glucose and pain control, 20 mg of triamcinolone appears to be recommended rather than 40 mg in patients with diabetes. Clinical Trials registration : NCT01435707 Key words: Epidural steroid injection, low back pain, diabetes, blood glucose