Epidural Triamcinolone Research Articles

Effects and Mechanism of Epidural Administration of Triamcinolone Acetonide on Nerve Root Inflammation and Epidural Space Adhesion in Rabbits

This study aimed to investigate the effect and mechanism of triamcinolone acetonide on nerve root inflammation and epidural adhesion in rabbits. The experiment involved 30 male New Zealand white rabbits, which were divided into three groups: Model, Dexamethasone, and Triamcinolone. After establishing the rabbit model of nerve root inflammation and epidural adhesion, dexamethasone and triamcinolone acetonide were injected through the epidural catheter. The results showed that triamcinolone acetonide significantly reduced nerve root inflammation, epidural adhesion, and nerve root pain. It also decreased the mRNA expression levels of NF-KB, TLR9, IL-6, and TNF-α in spinal cord tissue and spinal nerve roots. Compared with the dexamethasone group, the triamcinolone group had a lower Rydell-Balaz score, indicating less epidural adhesion. The Paw Withdraw Threshold and Paw Withdraw Latency decreased significantly in the triamcinolone group compared to the model group, and there was no obvious nerve root inflammatory reaction in the triamcinolone group. Therefore, epidural triamcinolone acetonide injection may be an effective treatment to reduce nerve root inflammation, epidural adhesion, and nerve root pain by inhibiting the NF-KB/TLR9-mediated inflammatory response.

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.

PSAT052 Iatrogenic Cushing's Syndrome With a Remote History of Synthetic Glucocorticoid Use in the Setting of a CYP3A4 Inhibitor – Location Matters

Abstract Introduction The most common cause of Cushing's syndrome is iatrogenic due to the exogenous administration of glucocorticoids (GCs). Exogenous GCs disrupt the hypothalamic-pituitary-adrenal (HPA) axis by reducing ACTH production, thereby suppressing cortisol production by the adrenal gland. The degree of HPA axis suppression and recovery varies by the formulation, dose, duration, frequency, timing, and location of GC administration. It is also well known that the clearance of GCs is delayed by inhibitors of cytochrome P450 (CYP) 3A4 isoenzyme. Here we report a case in which a patient on cobicistat developed iatrogenic Cushing's syndrome (ICS) even with a remote history of GC use. Clinical Case A 34-year-old male with Human Immunodeficiency Virus (HIV) on cobicistat and a history of a motor vehicle accident was referred for evaluation of ICS. The patient was started on triamcinolone epidural injections after the accident and developed a ruddy face, weight gain, posterior neck fat redistribution, and purple abdominal striae. He received a total of nine injections over three months at an unknown dose with the last injection being given two years ago. His symptoms improved after stopping the regimen. He received no GCs again until four months prior to presentation when he completed a 4 mg methylprednisolone taper and the cushingoid phenotype returned. Biochemical workup was consistent with HPA axis suppression: morning cortisol <0.5 mcg/dL (4-22 mcg/dL), ACTH <5 pg/mL (6-50 pg/mL), and DHEAS 18 mcg/dL (106-464 mcg/dL). Synthetic glucocorticoid screen was positive for methylprednisolone 5.3 mcg/dL (n <0.10 mcg/dL) and triamcinolone 0.29 mcg/dL (n <0.1 mcg/dL). The patient denied any surreptitious GC use. We concluded the patient still had unmetabolized triamcinolone even after two years due to drug interactions from cobicistat, which is a CYP3A4 inhibitor. Moreover, epidural triamcinolone has the longest half-life, 523 hours, compared to oral or intraarticular injections. Clinical Lesson: GCs are primarily metabolized in the liver by CYP3A4. Very few cases have been reported with the use of cobicistat and the cushingoid phenotype typically appears within 3-6 months of the GC use. However, our patient had detectable triamcinolone and return of ICS two years after epidural injections. It is not enough to know whether a patient received GCs; it is also essential to know how it was given and the location of the injection as the half-lives vary depending on said location. This case reinforces the importance of pharmacovigilance and performing a thorough medication reconciliation, as even a remote history of steroid use in the setting of CYP3A4 inhibitors could lead to ICS. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Effects of calcitonin addition on epidural injection in patients with degenerative spinal canal stenosis: a randomized double blind clinical trial.

Objective: Back pain is reported to be the fifth most common reason for referral a patient to a physician and the most common disability in modern society. The present study aimed to evaluate the effects of calcitonin addition on epidural injection in patients with degenerative spinal canal stenosis in comparison with epidural triamcinolone injection. Methods: This clinical trial study was performed on 40 patients with degenerative spinal stenosis, referred to pain clinic of Rasoul Akram Hospital in 2018, who were randomly divided into two groups, intervention and control groups, including 20 individuals in each group. In the intervention group, 50 units of calcitonin were injected with 8 cc of ropivacaine 0.2%, whilst 80 mg of triamcinolone with 8 cc of ropivacaine 0.2% was injected in the control group. Functional disability was evaluated based on the Oswestry Disability Index and pain ratings were assessed using the Visual Analogue Scale. Results: Pain at 4 and 8 weeks after the procedure was significantly different between the two groups. A significant difference in the patient disability index was observed between the two groups at 8 and 12 weeks after the procedure. On the other hand, the rate of analgesic consumption at 4, 8, and 12 weeks after the procedure was significantly decreased in the calcitonin group (P < .001). Conclusions: Based on our results, injection of calcitonin into the epidural space can reduce the pain of the patients and their analgesic consumption compared to the group receiving steroids through the epidural space.

EFFICACY OF INTRA OPERATIVE USE OF TRIAMCINOLONE IN LUMBAR DISCECTOMY

Objective: To evaluate the effect of epidural application of triamcinolone during lumbar discectomy onpostoperative pain relief.&#x0D; Study Design: Case control study.&#x0D; Place and Duration of Study: Department of Neurosurgery, Combined Military Hospital Lahore, from Oct 2019to Feb 2020.&#x0D; Methodology: Thirty patients receiving intraoperative epidural triamcinolone application compared with30 controls objective assessment by T-scores of the Timed Up and Go test, back and sciatic leg pain by Visualanalog scale and for subjective functional impairment by oswestry Disability Index were calculated pre-op, postoperative day 2 and at 4 weeks.&#x0D; Results: The baseline demographics, disease specific features and preoperative impairment scores were similaramong both groups. At day post-operative day 2, subjective impairment on oswestry disability index for thesteroid group was (30.6 vs 36.2, p&lt;0.01), with significant difference in terms of objective functional impairmentscore between steroid group (T-score 128.2 vs 129.3, p&lt;0.01). At 4 weeks post operatively, the Objective functional impairment was also found to be significantly less in the steroid group (T-score 100.5 vs 110.3, p&lt;0.01), with less disabled steroid group patients with oswestry disability index (17.0 vs 24, p&lt;0.01). Complication rates in both groups were similar. The duration of hospital stay was shorter among the steroid group (5.0 vs 5.8 days, p=0.06).&#x0D; Conclusion: The application of triamcinolone in lumbar discectomy leads to benefit in both subjective andobjective pain parameters in the early postoperative period.

SUN-402 Iatrogenic Cushing's Syndrome following Epidural Steroid Injections in an HIV-Infected Patient on Treatment with Genvoya

Introduction: We report the first known case of iatrogenic Cushing's syndrome in a patient with concomitant use of epidural triamcinolone injections and Genvoya therapy for HIV. Clinical Case: A 76-year-old female with HIV and diabetes presented with two months of fatigue, 6lb weight loss, and uncontrolled hyperglycemia. Her HIV-RNA level was suppressed on Genvoya, a four-drug combination of elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide.1 She had received four 80 mg epidural triamcinolone acetonide injections six months apart for chronic back pain starting 18 months before admission. The most recent injection was one month before presentation. She reported fatigue, depressed mood and difficulty ambulating. Examination was notable for plethoric moon facies, proximal muscle weakness, and episodic hypotension. Endocrine evaluation revealed evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression with a low morning cortisol level of 4.5 mcg/dL (5-25 mcg/dL); repeat testing was undetectable at 0.8 mcg/dL. Response to Cosyntropin stimulation was adequate (cortisol 17.8 mcg/dL at 60 minutes). A urine synthetic glucocorticoid panel showed an elevated triamcinolone acetonide level of 0.69 mcg/dL (cutoff value 0.10, Mayo Medical Labs, MN). We hypothesized that the interaction between Genvoya and triamcinolone led to iatrogenic Cushing's syndrome with suppression of her endogenous HPA axis, via the inhibition of steroid metabolism by Cobicistat, a hepatic CYP3A4 inhibitor. By applying the Naranjo Nomogram for Causality and the Drug Interaction Probability Scale to this interaction, we estimated a score of 5 (probable) and 6 (probable), respectively. Her antiretroviral medication was changed to emtricitabine, tenofovir alafenamide, and dolutegravir. She was started on maintenance hydrocortisone to prevent an adrenal crisis, with immediate improvement in fatigue, muscle weakness, and improved ambulation. A repeat urine glucocorticoid panel, within three days of her HIV regimen being changed, showed a decrease in triamcinolone levels to 0.32 mcg/dL. Conclusion: Cobicistat, a CYP3A4 inhibitor, can potentiate pharmacokinetic drug interactions with the concurrent use of other medications metabolized via this pathway. A literature review revealed a single case report of adrenal insufficiency following triamcinolone injections while on the HIV medication Stribild, which also contains cobiscistat.2 To our knowledge, there are no prior reports of Cushing's syndrome with Genvoya and exogenous steroids. We aim to increase awareness of this potential interaction to avoid adverse effects in patients on Genvoya also receiving corticosteroids.

To study the effect of Triamcinolone injection for low back pain due to lumbar disc herniation

Introduction: Low back pain is one of the most common complaints in the general population which represents a significant public health problem. Epidural Steroid Injection is being considered as a simple, effective and minimally invasive treatment modality for lumbar disc herniation. However, most studies only find a short-term benefit. In Bhutan, till date, no study has been done in Bhutan on this subject. The objective of our study was to find the effect of epidural steroid injection for low back pain due to lumbar disc herniation.&#x0D; Methods: An observational one-year-period study completed in Jigme Dorji Wangchuck National Referral Hospital. Symptomatic and positive Magnetic Resonance Imaging patients with lumbar disc herniation were included in our study. Pain scores were collected using Numeric Rating Scale at three different points of study. We also included patients’ age, weight and trauma history as some of the independent variables to study their associations with pain scores. The data obtained were analyzed using the Stata software program. One way repeated measures ANOVA was used to assess the significant difference in pain score.&#x0D; Results: Out of 100 participants recruited for the study, 91 of them completed demographic data and only 81 patients completed follow-up till 4 weeks post-treatment for demographic analysis and analytical analysis, respectively. There was a significant difference in pain scores in all three different points of study (p &lt;0.01). No significant difference was observed in the pain scores amongst different age groups, gender, occupation and trauma history (p &gt;0.05) at all three points of study.&#x0D; Conclusion: Our study observed a significant short-term benefit from epidural Triamcinolone injection for symptomatic lumbar disc herniation.

Comparison of Trans-Foraminal Epidural Triamcinolone with or Without Local Anesthetic in Lumbar DISC Herniation for Pain Relief

Comparison of Trans-Foraminal Epidural Triamcinolone with or Without Local Anesthetic in Lumbar DISC Herniation for Pain Relief

Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study.

OBJECTIVE The purpose of this study was to investigate whether the intraoperative application of an epidural steroid (ES) on the decompressed nerve root improves short- and midterm subjective and objective clinical outcomes after lumbar microdiscectomy. METHODS This study was a retrospective analysis of a 2-center database including consecutive cases in which patients underwent lumbar microdiscectomy. All patients who received ES application (40 mg triamcinolone, ES group) were matched by age and sex to patients who had not received ES application (control group). Objective functional impairment (OFI) was determined using age- and sex-adjusted T-scores of the Timed Up and Go (TUG) test. Back and leg pain (visual analog scale), functional impairment (Oswestry Disability Index [ODI], Roland-Morris Disability Index [RMDI], and health-related quality of life (hrQoL; 12-Item Short Form Health Survey [SF-12] physical component summary [PSC] score and EuroQol [EQ-5D index]) were measured at baseline, on postoperative day 3, and at postoperative week 6. RESULTS Fifty-three patients who received ES application were matched with 101 controls. There were no baseline demographic or disease-specific differences between the study groups, and preoperative pain, functional impairment, and hrQoL were similar. On postoperative day 3, the ES group had less disability on the RMDI (mean 7.4 vs 10.3, p = 0.003) and higher hrQoL as determined by the SF-12 PCS (36.5 vs 32.7, p = 0.004). At week 6, the ES group had less disability on the RMDI (3.6 vs 5.7, p = 0.050) and on the ODI by trend (17.0 vs 24.4, p = 0.056); better hrQoL, determined by the SF-12 PCS (44.3 vs 39.9, p = 0.018); and lower OFI (TUG test T-score 100.5 vs 110.2, p = 0.005). The week 6 responder status based on the minimum clinically important difference (MCID) was similar in the ES and control groups for each metric. The rates and severity of complications were similar, with a 3.8% and 4.0% reoperation rate in the ES group and control group, respectively (p = 0.272). There was a tendency for shorter hospitalization in the ES group (5.0 vs 5.8 days, p = 0.066). CONCLUSIONS Intraoperative ES application on the decompressed nerve root is an effective adjunct treatment that may lower subjective and objective functional impairment and increase hrQoL in the short and intermediate term after lumbar microdiscectomy. However, group differences were lower than the commonly accepted MCIDs for each metric, indicating that the effect size of the benefit is limited. ■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective cohort trial; evidence: Class II.

Hypothalamo-pituitary-adrenal axis after a single epidural triamcinolone injection.

To quantify adrenocorticotropin and cortisol secretion after epidural glucocorticoid injection. Eight men (ages 25-63 year) were studied at baseline, 1, 4, and 12 weeks after triamcinolone (80 mg) injection epidurally. Adrenocorticotropin (pg/mL) and cortisol (µg/dL) were measured every 10 min for 4 h, and after Corticotropin-releasing hormone (CRH) (1 µg/kg) injection. Epidural triamcinolone markedly suppressed: (1) pre-CRH injection ACTH (from 18 ± 3.1 to 4.8 ± 0.4: P < 0.01) and cortisol (from 12.2 ± 1.6 to 1.6 ± 0.3: P < 0.0001) at week 1, with recovery at 4 weeks, and (2) CRH-stimulated 3-h summed ACTH (from 633 ± 116 to 129 ± 10 pg/mL, P < 0.0001), and 3-h summed cortisol at week 1 (from 385 ± 29 to 56 ± 22 µg/dL, P < 0.0001) and 4 weeks (284 ± 53; P < 0.01). Serum cortisol was <18 µg/dL in eight of eight men at 4 weeks, and six of eight men at week 12. Urinary-free cortisol (µg/24 h) remained low at week 12: baseline (60 ± 6.5); week 1 (9.0 ± 1.3, P < 0.01); week 4 (36 ± 8.6) and week 12 (38 ± 4.1). Urinary cortisol/cortisone ratios rose at week 4 only. Serum triamcinolone peaked at week 1 (16/16 samples), declining at week 4 (13/16 samples) and week 12 (6/16 samples). Relatively small group. Epidural triamcinolone suppresses unstimulated and CRH-stimulated ACTH and cortisol secretion for 1-4 weeks but urinary free cortisol ≥12 weeks. Suppression of ACTH and cortisol after glucocorticoid treatment is thus complex.

Safety of epidural triamcinolone acetonide use during lumbar decompression surgery in pediatric patients: an association with delayed pseudomeningocele formation.

OBJECTIVE The complication profile of epidural triamcinolone acetonide use during lumbar decompression surgery is not known. However, isolated reports of increased risk of delayed CSF leakage with the use of triamcinolone acetonide in adult spinal surgery patients have been published. The purpose of this study was to determine the safety of epidural triamcinolone acetonide use in conjunction with lumbar decompression surgery in pediatric patients. METHODS The medical records of all patients who underwent lumbar decompression surgery with or without discectomy between July 1, 2007, and July 31, 2015, were retrospectively reviewed. RESULTS During the study period, 58 patients underwent 59 spine procedures at Texas Children's Hospital. There were 33 female and 25 male patients. The mean age at surgery was 16.5 years (range 12-24 years). Patients were followed for an average of 38.2 months (range 4-97 months). Triamcinolone acetonide was used in 28 (of 35 total) cases of discectomy; there were no cases of delayed symptomatic CSF leaks (0%) in the minimally invasive and open discectomies. On the other hand, triamcinolone acetonide was used in 14 (of 24 total) cases of multilevel laminectomy, among which there were 10 delayed CSF leaks (71.4%) requiring treatment. The use of triamcinolone acetonide in patients who underwent multilevel laminectomy was significantly associated with an increased risk of delayed CSF leaks or pseudomeningoceles (Fisher's exact test, p < 0.001). CONCLUSIONS There was an unacceptable incidence of delayed postoperative CSF leaks when epidural triamcinolone acetonide was used in patients who underwent multilevel laminectomy.

Esophageal infections: an update.

Infectious esophagitis generally occurs in patients with impaired immunity. Although methods to suppress the immune system evolve, the potential infectious consequences are poorly understood. The purpose of this article is to review the risk factors, diagnosis, and treatment of infectious esophagitis. Minimal pediatric data, including a few case reports and series, involve infectious esophagitis. Esophageal infections are usually caused by the following microbes, in order starting with the most common: Candida albicans, herpes simplex virus, and cytomegalovirus. Uncommon risk factors in these and other reports include epidural triamcinolone and oral budesonide in addition to more common risk factors such as HIV infection, chemotherapeutic agents, and transplant immunosuppressive medications. Rare reports involve immunocompetent patients and treatment of these patients is controversial. Understanding of infectious esophagitis is growing, and risk factors, diagnosis, and treatments are evolving.

Epidural chronic inflammatory mass of the lumbar spine in a human immunodeficiency virus positive patient with a history of repeated epidural injections

This study is a rare case of an epidural chronic inflammatory mass of the lumbar spine in an HIV-positive patient with a history of 12 epidural injections for 3 years because of chronic low back pain (LBP). A 61-year-old man had a 10year history of LBP and buttock pain. He also has been HIV-positive for 4 years. Patient underwent magnetic resonance imaging (MRI) at the lumbar region. TheMRI showed degenerated disc bulging, mild stenosis, and hypertrophied ligament flavum at multiple levels in the lumbar spine (Fig. 1). The LBP was treated with epidural triamcinolone and ropivacaine injection, total of 12 treatments at a pain clinic, but 3 years later, his back pain and bilateral buttock

Epidural triamcinolone for management of low back pain with radiation- a comparative study of two dose regime

Background: Low back pain is a very common specially in elderly people. Relief of pain is associated with decrease in morbidity, shorten hospital stay and increase patients’ satisfaction. Nerve block by epidural steroid and local anaesthetic is an acceptable method to reduce low back pain. Aim and objective: The present study was performed to compare low dose (40 mg) and high dose (80 mg) Triamcinolone to see their effectiveness and side effects in controlling low back pain. Method: This study was a randomized controlled trial. 60 patients with low back pain with radiation, and with positive CT/MRI support has been randomly selected by blind envelop method and divided into two groups, 30 patients in each. Group-A, patients received inj. Triamcinolone (40 mg) and Group-B patients received inj. Triamcinolone (80 mg) epidurally. Results: Both dosage produced effective analgesia in low back pain as assessed by visual analogue scale (VAS) and verbal rating scale (VRS) for the period up to 30 days after administration. Haemodynamic changes showed no significant difference between the two drugs after 30 days. Both drugs produced significant rise of fasting plasma glucose and leucocytosis for the period up to 30 days after administration. Conclusion: Low back pain can be effectively reduced by epidural low dose Triamcinolone (40 mg). DOI: http://dx.doi.org/10.3329/jbsa.v23i1.18153 Journal of BSA, 2010; 23(1): 14-18

Iatrogenic cushing syndrome secondary to ritonavir-epidural triamcinolone interaction: an illustrative case and review.

HIV positive patients on ritonavir-containing antiretroviral therapy (ART) can develop iatrogenic Cushing syndrome (IACS) and adrenal insufficiency as a result of drug-drug interactions with inhaled or intranasal glucocorticoid therapy. Reports related to epidural triamcinolone injections are relatively uncommon but increasingly reported. We describe a 48-year-old woman with immunologically and virologically well-controlled HIV on ritonavir-based ART, who developed headache, dizziness, and candida and herpes simplex virus (HSV) ulcerative esophagitis 7 days after receiving an epidural triamcinolone injection for cervical radicular pain. Iatrogenic Cushing syndrome and relative adrenal insufficiency were suspected and proven. The patient's ART was changed to a non-HIV protease inhibitor- (PI-) containing program, her symptoms improved, and she did not require hydrocortisone replacement. In this paper, we review the literature on IACS and relative secondary adrenal insufficiency from epidural triamcinolone injections in HIV patients on ritonavir-containing ART regimens. A high index of clinical suspicion is needed for diagnosis. Prevention of drug-drug interactions by taking a thorough medication history for patients on ritonavir-containing ART regimens before prescribing any form of corticosteroid is crucial and effective and sustained interdisciplinary communication in the care of such patients.

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 &lt; 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

Raltegravir-induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome – Implications for clinical practice and patient safety

This case report describes two severe antiretroviral drug adverse reactions that occurred in the same patient. A 55-year-old HIV-positive African woman received a single epidural triamcinolone injection for pain relief of postherpetic neuralgia. Forty-one days later, she developed severe iatrogenic Cushing's syndrome due to the drug-drug interaction between triamcinolone and her boosted protease inhibitor therapy. The patient's antiretroviral regimen was thus changed to replace her protease inhibitor with the integrase inhibitor raltegravir. Shortly after commencing the drug, the patient developed a severe adverse drug reaction manifesting as Drug Reaction (or Rash) with Eosinophilia and Systemic Symptoms (DRESS) syndrome. First described in 1996, this hypersensitivity syndrome presents with severe skin reaction as well as fever, rash, lymphadenopathy and internal organ involvement with marked eosinophilia. Clinicians should be aware of raltegravir-induced DRESS syndrome as well as the potential for drug-drug interactions due to protease inhibitor-based therapy.

Clinical Comparison of Effectiveness of Epidural Triamcinolone and Betamethasone in Discal Radiculalgia: A Prospective, Randomized Study

Objectives: This study was planned to compare the efficacies of epidural betamethasone and triamcinolone injections in discal radiculalgia.Methods: Seventy patients complaining unilateral discal radiculalgia with acute discogenic pain were included in the study. The patients were randomly assigned to two groups. All patients received a single 20 ml epidural dose of steroid and 0.125 percent bupivacaine combination. The patients in group 1 and group 2 received betamethasone [14 mg] and triamcinolone [80 mg] by epidural injections, respectively. After the epidural steroid injection, the efficacy of treatment was assessed with visual analog scale [VAS], straight leg elevation test [0° = worst, 85° = best], and Oswestry Disability Index. The injection was repeated at the end of the second week, in case of partial improvement, and at the end of the sixth week if the recovery from pain was still incomplete. All patients were given amitriptyline [10 to 50 mg/day orally] for a period of six months.Results: There ...

Uterine bleeding in a postmenopausal women following epidural triamcinolone acetonide injection: A case report.

Epidural steroid therapy for herpes zoster associated pain is known to be effective with rare complications. However, certain amount of epidurally-injected steroid may be absorbed and affect endocrinological system. Specially, triamcinolone acetonide has high affinity for progesterone receptors and may influence mensturation. We report a case of a postmenopausal women treated with 40 mg of epidural triamcinolone acetonide twice with a two week interval and followed a large amount of uterine bleeding.

Iatrogenic Cushing Syndrome after Epidural Triamcinolone Injections in an HIV Type 1–Infected Patient Receiving Therapy with Ritonavir‐Lopinavir

We report the first case of a human immunodeficiency virus type 1 (HIV-1)-infected individual receiving combination antiretroviral therapy, which included ritonavir, who developed Cushing syndrome with profound complications after epidural triamcinolone injections. This case highlights the potential of ritonavir interactions even with local injections of a corticosteroid.