Intramuscular Corticosteroids Research Articles

Comparison of local versus intramuscular steroid injection in patients with carpal tunnel syndrome: A prospective open label randomized clinical trial

AimThis study compared the efficacy and safety of local corticosteroid injection (LCI) vs intramuscular (IM) corticosteroid injection in mild to moderate carpal tunnel syndrome (CTS). MethodsThis is an open labeled, randomized controlled trial conducted during December 2021 to August 2023. Eighty-six patients with CTS were randomized in 1:1 ratio to receive either single 40 mg methylprednisolone (MP) injection at the wrist (LCI arm), or single 40 mg MP intramuscular injection (IM arm) in the deltoid. Primary outcome was absolute Symptom Severity Scale (SSS) at 3 months. Secondary outcomes were SSS score at 1-month, Functional Status Scale (FSS) score at 1 and 3 months, and recurrence at 3 months and injection site pain assessed on visual analog (VAS) scale. ResultsMedian age was 45 (range 22 – 80) years, and 86 % were females. Baseline characteristics were comparable between groups. Mean SSS score at 3 months was similar in two arms (1.72 ± 0.71 vs 2.0 ± 0.93) with mean difference (MD) −0.03 (-0.31 to 0.25, p = 0.83) after adjusting for baseline SSS scores. LCI, however, resulted in significantly better SSS (1.48 ± 0.51 vs 1.88 ± 0.69, adjusted p = 0.04), and FSS scores (1.57 ± 0.44 vs 1.80 ± 0.66, adjusted p = 0.03) at 1 month compared to IM arm. Response rate (67.4 % vs 55.8 %; p = 0.30) and recurrence rate (17.1 % vs 22.6 %, p = 0.74) at 3 months were similar. Injection site pain was severe in LCI arm[median 5 (range 3 – 8) vs median 3 (range 2 – 6)]. ConclusionsIn patients with mild to moderate CTS, LCI resulted in better improvement in the BCTQ scores at 1 month compared to IM steroid. However, 3-month’s outcome was similar. Intramuscular steroid injection was better tolerated.

Clinical case report: intralesional corticosteroid application in recurrent tracheal stenosis

BACKGROUND: Benign tracheal stenosis in adults has three etiologies: secondary to prolonged intubation, idiopathic, and rheumatologic. The one associated with prolonged intubation has been described as a lesion due to the persistent pressure of the balloon on the tracheal mucosa, which predisposes to a regional hyperinflammatory response; for that reason, modulating treatments for this response have been proposed as an alternative to classical surgical treatment. To date there is no treatment defined as Gold-Standard; both open and endoscopic treatments are practiced, among the last described, an option is intralesional corticosteroids injection. CASE REPORT: This is a 47-year-old woman with a history of prolonged mechanical ventilation; months later she was diagnosed with tracheal stenosis, initial treated with dilation and stent placement, with subsequent complications (stent migration, reinterventions due to respiratory distress). The patient sought medical attention due to dyspnea, stridor, productive cough, halitosis and general malaise, finding severe tracheal stenosis (98%) by flexible fiberoptic bronchoscopy. EVOLUTION: Using rigid bronchoscopy, the stent was removed, dilation was performed, and we administered intralesional corticosteroid for one time, with a good immediate response; in addition, a course of intramuscular corticosteroids was administered for two days. Six months after the procedure, the patient remained without recurrences, with a stable tracheal stenosis of 30%. CONCLUSION: After the bibliographic review carried out, as well as the successful experience we had with the patient, we agree with the available literature that this new treatment option is adequate for its application, although we recognize that larger studies are required to define the precise indications and an optimal protocol for its establishment.

CHRONIC SPONTANEOUS URTICARIA, LOW HISTAMINE DIET AS A TREATMENT

<h3>Introduction</h3> Chronic Spontaneous Urticaria (CSU) is defined as urticaria that persists longer than six weeks. It was previously known as Chronic Idiopathic Urticaria. The current mainstay treatments for CSU include antihistamines and immunomodulators. The exact pathogenesis of CSU remains unclear. Here, we discuss two patients treated for CSU who demonstrated persistently elevated histamine levels with normal tryptase suggesting a non-mast-cell-mediated histamine elevation. Both were responsive to low-Histamine diet (LHD) as a primary treatment. <h3>Case Description</h3> A 50-year-old male presented for CSU. The patient was placed on intramuscular and oral corticosteroids for his symptoms with minimal relief. Laboratory studies revealed an elevated histamine level of 5.1 ng/mL and a normal tryptase level of 7.1 mcg/L. The patient was placed on LHD and subsequently reported complete resolution of CSU. 38-year-old male presented for a pruritic skin rash diagnosed as CSU. The patient was previously placed on antihistamines and steroid cream. Laboratory studies revealed multiple elevated histamine levels greater than 6.0 ng/mL and normal tryptase levels of 6.5 and 7.7 mcg/L. The patient was placed on LHD with satisfactory resolution of symptoms. <h3>Discussion</h3> Persistently elevated histamine levels may contribute to CSU in a subgroup of patients who may be experiencing symptoms due to a non-mast-cell-mediated histamine elevation. Further research is needed to evaluate LHD as a primary treatment for CSU articulately in the presence of persistently elevated histamine.

A RARE CASE OF PROTRACTED ANAPHYLAXIS CAUSED BY ACETAMINOPHEN

<h3>Introduction</h3> Acetaminophen is a rare but recognized etiology of anaphylaxis. We present an unusual case of protracted anaphylaxis requiring intensive care unit (ICU) monitoring following intravenous (IV) acetaminophen. <h3>Case Description</h3> A 49-year-old female with a history of ovarian cancer presented to the emergency department with pruritic urticarial rash, fevers, tachycardia, and relative hypotension. A sepsis workup was initiated. Hemodynamics improved with broad-spectrum antibiotics and fluids. Due to symptomatic high-grade fevers, IV acetaminophen was administered. Her rash, tachycardia, and relative hypotension worsened one hour following infusion. Despite resuscitation with diphenhydramine and fluids, she remained tachycardic and febrile, prompting treatment for suspected anaphylaxis with intramuscular epinephrine, corticosteroids, and additional diphenhydramine. Her rash and hemodynamics improved moderately. She was subsequently started on norepinephrine and transferred to the medical ICU, where she had two days of persistent tachycardia and fluctuating urticarial rash responsive to antihistamines. Infectious workup was unrevealing. She later revealed a prior history of urticaria following home oral acetaminophen. Tryptase drawn one hour after decompensation was elevated to 23.8 mcg/L (baseline 3.2 mcg/L). The diagnosis was made of IgE-mediated reaction to acetaminophen causing protracted anaphylaxis. <h3>Discussion</h3> Anaphylaxis secondary to acetaminophen is an uncommon but recognized phenomenon. An initial differential included pseudoallergic reaction, given acetaminophen can be a weak cyclooxygenase-1 inhibitor causing direct mast cell activation and urticaria; however, this does not classically cause hypotension. Overall, this presentation may represent a mixed picture of sepsis of unclear etiology with superimposed IgE-mediated reaction. It is important to recognize anaphylaxis can co-exist with sepsis and manifest with overlapping symptoms.

33863 Successful use of dupilumab for treatment of atopic dermatitis in a liver transplant patient

There is a paucity of data regarding the use of dupilumab treatment of atopic dermatitis (AD) in solid organ transplant patients. We report a case of successful treatment of AD in an orthotopic liver transplant (LT) patient with dupilumab with favorable clinical response and no observed side effects throughout two years of treatment. A 65-year-old Caucasian female with history of orthotopic LT for cirrhosis 17 year prior, presented to dermatology clinic with 2-year history of a pruritic eruption involving bilateral extremities. Punch biopsy revealed spongiotic dermatitis with eosinophils, consistent with atopic dermatitis, allergic contact dermatitis, or id reaction. Photo-patch testing revealed positivity for methyldibromo glutaronitrile, benzalkonium chloride, and benzophenone. Despite numerous trials of medium- and high-potency topical steroids as well as intramuscular and oral corticosteroids, the patient experienced continued pruritus and repeated flares. Phototherapy and immunosuppressives including methotrexate and cyclosporine were contraindicated due to the patient’s photo-allergy and LT status on a stable dose of tacrolimus, respectively. After extensive discussion with the patient’s primary care and transplant teams, the decision was made to begin dupilumab. After 1 month of treatment, the patient experienced near clearance of rash, minimal flares that were easily controlled with adjunct topical corticosteroids, and a 90% improvement in subjective pruritus, with no adverse effects. This response was sustained throughout an additional 2 years of treatment. We report this case of successful dupilumab treatment of AD in a LT patient to raise awareness to the safety and efficacy of its use in this patient population.

Pressure Injury as Insidious Comorbidity in Ventilator-Dependent Respiratory Failure (VDRF) Secondary to COVID-19: A Case Report

Research ObjectivesTo highlight opportunities to decrease adverse outcomes in the acute management of COVID-19 infection.DesignDescriptive single-subject study.SettingInpatient/Acute rehabilitation.ParticipantsA 47-year-old female with Ventilator-Dependent Respiratory Failure (VDRF) secondary to COVID-19.InterventionsIn the ED, Patient was started on antibiotics (azithromycin, ceftriaxone), nebulizer treatments, intravenous fluids, and intramuscular corticosteroids (methylprednisolone).On hospital admission, she was initiated on antiviral Remdesivir and received 1 unit of convalescent plasma. Self-proning was encouraged, yet Patient required progressive increase in oxygen (O2) supplementation. She was intubated from Hospital Day (HD) 4 to 7. Wound care assessments began on HD10; wounds to low back and bilateral buttocks were noted. By HD15, O2 requirements were further weaned and Patient was transferred to Acute Inpatient Rehab.On Rehab admission, Patient had Leukocytosis and wounds noted as “Unstageable”. Antibiotic coverage was increased (Cefepime). By HD28/ Rehab Day (RD) 13, wound culture was positive, and antibiotic regimen was further supplemented (Metronidazole, Fluconazole, Daptomycin).MRI thoracic spine and pelvis demonstrated “necrotizing soft-tissue infection”. Surgical debridement occurred HD31/RD16 with subsequent anemia, requiring transfusion. She underwent additional surgical debridement on HD38/RD23 and was returned to the Acute floors. She was discharged to home with outpatient wound care on HD53.Main Outcome MeasuresWound size (area).ResultsWound size: Hospital Day (HD) 10: 284.39cm2; HD16/Rehab Day (RD) 1: 698.6cm2; HD34/RD19: 265.66; HD39:747.72cm2; HD51: Area = 992.80cm2.∆Area, Pre-Rehab (HD16-HD10): (+) 414.2cm2; ∆Area, Rehab (HD34/RD19-HD16/RD1): (-) 439.94; ∆Area, Post-Rehab (HD51-HD34): (+) 727.14.ConclusionsInpatient Rehabilitation practices may help ameliorate pressure injury in cases of VDRF secondary to COVID-19 infection. Further study is warranted on the potential integration of such practices in this patient population, as a preventative measure in the Acute and/or Critical care settings.Author(s) DisclosuresAffiliation: HCA Healthcare (MountainView Hospital)Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Intramuscular Corticosteroid Therapy in the Treatment of Alopecia Areata: A Time-to-Event Analysis.

IntroductionIntramuscular corticosteroids (IMC) have gained popularity for the treatment of severe alopecia areata (AA) in recent years; however, evidence on their efficacy and safety is still limited.ObjectiveTo evaluate the efficacy, relapse rate, and tolerability of IMC in the treatment of AA, as well as factors associated with treatment outcomes.MethodsTime-to-event analysis was performed on patients with severe, extensive, or rapidly progressive AA receiving IMC. The IMC regimen comprised triamcinolone acetonide 20–40 mg/mL injected every 4–6 weeks. The evaluated outcomes included initial (25% regrowth), significant (75% regrowth), and complete hair regrowth (100% regrowth). Relapse and adverse events were also noted. Factors associated with treatment outcomes and relapse were analyzed using the Cox proportional hazards model.ResultsA total of 101 patients were eligible for analysis. Significant hair regrowth was obtained in 80.2% of the patients (n = 81), in a median time of 3.4 months (95% confidence interval [CI] = 2.9–4.4). Complete hair regrowth was achieved in 48.5% of the subjects (n = 49), and relapse was observed in 47.5% (n = 48). Acneiform eruption was the most common adverse effect. Multivariable analysis revealed that nail involvement was a negative predictor of significant hair regrowth (adjusted hazard ratio [HR] = 0.04, 95% CI = 0.01–0.55; P = 0.015), whereas duration of AA longer than 6 months was associated with disease recurrence (adjusted HR = 4.02, 95% CI = 1.52–4.66; P = 0.005).ConclusionThis study demonstrated the efficacy and safety of IMC in the treatment of severe or active AA; however, the relapse rate remained relatively high after discontinuation of the therapy. Nail involvement was a negative predictor of significant hair regrowth, while disease duration longer than 6 months predicted AA relapse.

Route of Administration of Corticosteroids and Asthma Relapse after Acute Care; Appraisal of Evidence on Effectiveness and Safety

Patients managed for acute exacerbation of asthma in acute settings respond to standard management protocol involving systemic and oral steroids. However, relapses are common due to poor adherence to tapering doses of oral steroids. Intramuscular (IM) administration of corticosteroids has been shown to be equipotent to oral steroids with the added advantage of convenient dosing and improved adherence. However, the role of the route of administration of corticosteroids related to relapse of asthma attacks after acute care has not been fully explored. To find and appraise up-to-date evidence in the literature that compares the effectiveness and safety of IM corticosteroids o a short-course oral corticosteroid in the treatment of asthma patients in acute care settings. The principles of evidence-based medicine (EBM) were used. Suitable articles were identified using MEDLINE, Cochrane library, and Google scholar. Titles and summary texts were reviewed. The full article of the relevant article was downloaded for critical appraisal of methodological quality using a measurement tool to assess systematic review 2 (AMSTAR 2). In applying AMSTAR 2 to the selected systematic review article, it was noted that the investigators followed most of the requirements. However, adequate investigation of publication bias and discussion of its likely impact on the review’s result was not done by the researchers. No significant differences in effectiveness and safety were observed between IM corticosteroids and oral corticosteroids among this category of patients. Additional studies are required to compare different IM and oral corticosteroid preparations. Keywords: Acute exacerbation of Asthma, AMSTER 2, Evidence-based medicine, Route of administration of corticosteroids.

Lung function, airway and peripheral basophils and eosinophils are associated with molecular pharmacogenomic endotypes of steroid response in severe asthma

IntroductionAsthma is a complex disease with heterogeneous expression/severity. There is growing interest in defining asthma endotypes consistently associated with different responses to therapy, focusing on type 2 inflammation (Th2) as...

Intramuscular corticosteroid injections in seasonal allergic rhinitis: A systematic review.

ObjectiveSeasonal allergic rhinitis (SAR) is an exaggerated immunological reaction to allergens (pollen) in the air. In a small subgroup of patients, SAR can be difficult to control with first‐line therapy. Intramuscular corticosteroid injections (IMCIs) are an additional treatment in this subgroup of SAR patients. The aim of this systematic review is to investigate the efficacy and safety of IMCIs in SAR.MethodsTitles and abstracts were independently screened, followed by full‐text screening based on predefined criteria. Included articles were critically appraised using the Cochrane Risk of Bias 2 (RoB 2) tool. The primary outcome is reported as the final conclusion about efficacy that was stated in the included studies. The secondary outcome is the safety of IMCIs with regard to long lasting side‐effects.ResultsThe search yielded 2139 records, of which 10 were relevant and valid for our clinical question. Critical appraisal showed high risk of bias, which was due to unclear description of methods. Four out of four placebo‐controlled, randomized controlled trials reported a significant and relevant difference in efficacy in favor of IMCIs compared with placebo. The occurrence of side‐effects was not different between IMCIs and placebo or oral corticosteroids (OCs).ConclusionThe outcome of this systematic review on trials concerning intramuscular steroid injections, despite being based on individual studies claiming favorable outcome with their use, is “inconclusive.” This is because of the epidemiological high risk of bias in these studies that were mostly executed more than 30 years ago. The “inconclusive” rating allows for a description as an “optional therapy” for severe cases in guideline formation.

Efficacy and Safety of Pharmacologic Interventions in Patients Experiencing a Gout Flare: A Systematic Review and Network Meta-Analysis.

To compare the relative efficacy and safety of pharmacologic antiinflammatory interventions for gout flares. We searched Ovid Medline, Embase, and Cochrane library for randomized controlled trials (RCTs) that compared pharmacologic antiinflammatory treatment of gout flares. We conducted a network meta-analysis (NMA) using a frequentist framework and assessed the certainty of evidence and made conclusions using the Grading of Recommendations Assessment, Development, and Evaluation for NMA. In the 30 eligible RCTs, canakinumab provided the highest pain reduction at day 2 and at longest follow-up (mean difference relative to acetic acid derivative nonsteroidal antiinflammatory drugs [NSAIDs] -41.12 [95% confidence interval (95% CI) -53.36, -29.11] on a 0-100 scale at day 2, and mean difference -12.84 [95% CI -20.76, -4.91] at longest follow-up; both moderate certainty; minimum important difference -19). Intravenous or intramuscular corticosteroids were inferior to canakinumab but may be better than the other commonly used interventions (low to very low certainty). For joint tenderness, canakinumab may be the most effective intervention at day 2. Acetic acid derivative NSAIDs improved joint swelling better than ibuprofen NSAIDs at day 2 (mean difference -0.29 [95% CI -0.56, -0.02] on a 0-4 scale; moderate certainty) and improved patient global assessment (PtGA) greater than ibuprofen NSAIDs at the longest follow-up (mean difference -0.44 [95% CI -0.86, -0.02]; moderate). Canakinumab may be superior to other alternatives and intravenous or intramuscular corticosteroids may be the second best in pain reduction. Acetic acid derivative NSAIDs may be superior to ibuprofen NSAIDs in improving joint swelling and PtGA.

Role Of Intramuscular Corticosteroids In Trigger Point Injections: A Narrative Review

Role Of Intramuscular Corticosteroids In Trigger Point Injections: A Narrative Review

Assessing the quality of antenatal corticosteroids in low- and middle-income countries: A systematic review.

The World Health Organization (WHO) recommends the administration of intramuscular antenatal corticosteroids to women at risk of preterm birth to prevent preterm-associated neonatal mortality and morbidity. Poor quality medicines are a major problem for health services in low- and middle-income countries (LMICs), however the quality of antenatal corticosteroids is not well understood. We aimed to conduct a systematic review of available studies describing the quality of recommended injectable antenatal corticosteroids (dexamethasone or betamethasone) in LMICs. Structured search strategy was applied to six databases (MEDLINE, EMBASE, CINAHL, International Pharmaceutical Abstracts, Global Index Medicus, WHO Medicines Quality Database), without year or language restrictions. Any primary study reporting any medicine quality parameter (Active Pharmacological Ingredient, pH and sterility) for injectable dexamethasone or betamethasone was eligible. Two authors independently screened studies for eligibility, extracted data on included studies and applied Medicine Quality Assessment Reporting Guidelines tool to assess study quality. Results were reported narratively, stratified by country of manufacture, organisation type and level of care. In total, 15,547 citations were screened with two eligible studies identified that focussed on dexamethasone quality (no studies of betamethasone were identified). One study included 19 samples from 9 LMICs, and the other included "less than 100 samples" from India. The prevalence of failed dexamethasone samples ranged from 3.14% to 32.2% due to inadequate Active Pharmacological Ingredient. A higher prevalence of failed dexamethasone samples were seen at the point of care and the public sector. Poor quality maternal and newborn health medicines can endanger women and newborns. Though available evidence on antenatal corticosteroids quality in LMICs is limited, results suggested poor quality dexamethasone may be prevalent in some countries. More primary studies are required to confirm these findings and guide policymakers on procurement of good-quality maternal and newborn health medicines.

Are Systemic Corticosteroids Causing Psoriasis Flare-Ups? Questionnaire for Danish Dermatologists, Gastroenterologists and Rheumatologists

Background: Psoriasis flare-ups and the change of morphology from nonpustular to pustular psoriasis following tapering and withdrawal of systemic corticosteroids have been reported. Despite these risks, systemic corticosteroids are still widely prescribed for patients with psoriasis, but the knowledge about psoriasis flare-ups and whether the physicians take precautions during these treatments is limited. Methods: We conducted a questionnaire study among all dermatologists, gastroenterologists and rheumatologists in Denmark who work at a hospital or in a private practice to investigate the use, opinion and experience with oral, intramuscular and intra-articular corticosteroids in the treatment of patients with psoriasis. Results: We received answers from a total of 248 physicians. Compared with oral and intramuscular corticosteroids, intra-articular corticosteroids were the most reported treatment in patients with psoriasis and only used by the rheumatologists. It was mainly the dermatologists and rheumatologists who had observed psoriasis flare-ups following treatment with oral, intramuscular and intra-articular corticosteroids. Half of the dermatologists (50%) and a fourth of the rheumatologists (29%) had observed at least one psoriasis flare-up following treatment with oral corticosteroids. About 10% of both the dermatologists and the rheumatologists had observed at least one psoriasis flare-up following treatment with intramuscular and/or intra-articular corticosteroids. Overall, 44% of the respondents took precautions, when they treated a patient with psoriasis with oral, intramuscular and intra-articular corticosteroids. Conclusion: The results from the questionnaire indicate that systemic corticosteroids for patients with psoriasis can cause flare-ups and should be used with care.

Autologous Fat Grafting for Correction of Intramuscular Corticosteroid Injection–Induced Fat Atrophy

Autologous Fat Grafting for Correction of Intramuscular Corticosteroid Injection–Induced Fat Atrophy

Intramuscular Corticosteroids for Acute Upper Respiratory Infections Affects Healthcare Utilization.

To examine the use of intramuscular corticosteroid (IMCS) injections for treatment of acute upper respiratory infections (URI) and the influence on healthcare utilization. This retrospective cohort study used patient encounter data from a large multicenter regional health care system between 2013 and 2017. Adult patients diagnosed with acute URI (acute pharyngitis, acute sinusitis, acute otitis media, and URI not otherwise specified) during ambulatory encounters were included. Follow-up encounters for a diagnosis of acute URI within 60 days were identified and patient characteristics, encounter details, and procedure codes were retrieved. Frequency data was used to calculate IMCS injection administration prevalence, utilization trends, and associations with covariates. Follow-up data for return encounters within 60 days for the same diagnosis was examined. Of the 153 848 initial encounters, 34 600 (22.5%) patients received IMCS injection for acute URI. Injection rates varied from 0.85% to 49.1% depending on specialty and practitioner type. Internal medicine, family medicine, urgent care, and otorhinolaryngology clinics most commonly administered IMCS. 3788 patients returned for a second encounter of which 751 (19.8%) received an injection. IMCS injection during the first encounter was associated with increased odds of repeat visit within 60 days (OR: 1.74; 95% CI: 1.61-1.88). IMCS use in the treatment of acute URI is highly prevalent despite lack of evidence for impact and safety. Prevalence is variable across multiple medical and surgical specialties including otorhinolaryngology. Administration of IMCS injection may contribute to the likelihood of a subsequent healthcare visit for the same indication.

Corticosteroids as standalone or add-on treatment for sore throat.

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012. To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children. We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess. We used standard methodological procedures expected by Cochrane. We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children. Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.

In patients with an acute asthma exacerbation, does a single intramuscular corticosteroid injection reduce recurrent exacerbations versus five days of oral corticosteroid treatment?

In patients with an acute asthma exacerbation, does a single intramuscular corticosteroid injection reduce recurrent exacerbations versus five days of oral corticosteroid treatment?

Pragmatic randomised controlled trial of very early etanercept and MTX versus MTX with delayed etanercept in RA: the VEDERA trial

ObjectivesWe sought to confirm in very early rheumatoid arthritis (ERA) a much greater superiority (30%) of first-line etanercept+methotrexate (ETN+MTX) over treat-to-target MTX (MTX-TT) than previously reported in ERA (14%); and...

P04 Co-designing a comparative randomised controlled clinical trial of corticosteroid regimens with children, young people and parents living with juvenile idiopathic arthritis

Abstract Background Previous research has identified the need for a randomised controlled trial (RCT) evaluating the most appropriate corticosteroid induction regimen to be used for children and young people (CYP) with juvenile idiopathic arthritis (JIA). A recent qualitative study found that parents and CYP understood trial concepts and were able to identify potential flaws in a proposed RCT. This confirms the need to involve parents and CYP in co-designing RCTs to best meet the needs of future trial participants. We aimed to co-design components of an RCT of corticosteroid regimens with CYP and parents living with JIA. Methods A focus group was conducted with CYP with JIA and parents as part of a wider consensus and discussion group meeting within the Steroid Induction Regimen for Juvenile Idiopathic Arthritis (SIRJIA) study in December 2018. The discussion focused on two components of the RCT design: i) Discussing the most appropriate treatment protocols; and ii) Addressing practicalities associated with an RCT. Results Two RCT protocol options, chosen through an online survey by a clear majority out of a possible eight protocols, were discussed and critiqued: i) Protocol A (intravenous vs intraarticular corticosteroid delivery); and ii) Protocol B (intravenous vs intraarticular vs intramuscular vs oral corticosteroid delivery). Several issues pertaining to both protocols were raised, related to the influence of age and past experience, routes of administration and concerns over randomisation. Participants emphasised the importance of clinicians/researchers discussing all of the potential risks with them. Participants also wanted enough information to make an informed choice. Participants emphasised the usefulness of combining trial visits with regular follow-up appointments to minimise the burden of taking part in an RCT and had a preference for their usual hospital being the site they visited. Some participants remarked that videos could be a useful way of conveying information beyond traditional participant information sheets. Some also felt that awareness of research opportunities is not equally accessible to them either, depending on where they lived in the country. Participants would want to be kept regularly updated about the progress of the RCT and felt that incentives were a good way of keeping people engaged, although some were apprehensive about hearing negative treatment results. With regards to dissemination, participants felt that study results should be readily available to them in an accessible format, should they wish to view them. Conclusion CYP and parents have a considerable amount of knowledge and experience which can shape the design of RCTs. With adequate support, complex concepts such as treatment protocols can be discussed and critiqued. Involving CYP and parents at the design stage of an RCT has been shown to eliminate some potential challenges in the future. Conflicts of Interest The authors declare no conflicts of interest.