Stout Alison, Friedly Janna, Standaert Christopher J
Evergreen Healthcare, 12039 NE 128th St Suite 500, Kirkland, WA 98034.
Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
PM R. 2019 Apr;11(4):409-419. doi: 10.1002/pmrj.12042. Epub 2019 Mar 29.
Local glucocorticoid injections are often used to treat joint, soft tissue, or spinal pain, but the systemic side effects associated with these injections are poorly understood and not well recognized. There are significant known risks to systemic administration of glucocorticoids. However, there are no guidelines that address issues of systemic absorption, overall systemic risks, or other side effects of locally injected glucocorticoids. For this review, a literature search was performed, and the available evidence on systemic absorption and clinical side effects of intra-articular and epidural glucocorticoids was synthesized. The goal was to improve clinical understanding of risks associated with these injections. Existing data suggest there is significant individual variability in the amount of systemic absorption and clinical effects of locally injected glucocorticoids. However, it is clear that both intra-articular and epidural injections can have systemic effects for weeks and that complications may be associated with their use, including Cushing syndrome, loss of bone density, infection, and hyperglycemia. The concurrent use of oral steroids, the number of injections, and the type and dose of glucocorticoids used all are important considerations in estimating risks. The total dose calculation of cumulative glucocorticoid exposure should include all local injections. Caution should be exercised when local glucocorticoid injections are used in higher risk patients, such as postmenopausal women, people with diabetes, and those considering surgery in the near term. Better provider awareness of possible systemic risks should improve decision making and informed consent with patients when considering intra-articular and epidural steroid injections for painful conditions. LEVEL OF EVIDENCE: IV.
局部糖皮质激素注射常用于治疗关节、软组织或脊柱疼痛，但这些注射相关的全身副作用了解甚少且未得到充分认识。全身应用糖皮质激素存在重大已知风险。然而，目前尚无指南涉及局部注射糖皮质激素的全身吸收、总体全身风险或其他副作用问题。为进行本综述，我们开展了文献检索，并综合了有关关节内和硬膜外糖皮质激素全身吸收及临床副作用的现有证据。目的是提高对这些注射相关风险的临床认识。现有数据表明，局部注射糖皮质激素的全身吸收量和临床效果存在显著个体差异。然而，很明显关节内和硬膜外注射均可在数周内产生全身效应，且其使用可能会引发并发症，包括库欣综合征、骨密度降低、感染和高血糖。口服类固醇的同时使用、注射次数以及所用糖皮质激素的类型和剂量都是评估风险时的重要考虑因素。累积糖皮质激素暴露的总剂量计算应包括所有局部注射。在高风险患者（如绝经后女性、糖尿病患者以及近期考虑手术的患者）中使用局部糖皮质激素注射时应谨慎。当考虑为疼痛性疾病进行关节内和硬膜外类固醇注射时，临床医生对可能的全身风险有更好的认识应能改善决策并使患者做出知情同意。证据级别：IV级
