Evidence-based answers from the Family Physicians Inquiries Network

Erin Kallock, MD; Do intra-articular steroid Jon O. Neher, MD Valley Family Medicine Residency, Renton, Wash. injections aff ect glycemic control Leilani St. Anna, MLIS, AHIP University of Washington in patients with diabetes? Health Services Library, Seattle

EVIDENCE-BASED ANSWER

yes, but the clinical importance mendation [SOR]: B, small cohort studies). A is minimal. A single intra-articular Intra-articular steroid injections into the steroid injection into the knee produces shoulder may briefl y raise postprandial (but acute hyperglycemia for 2 or 3 days in pa- not mean) glucose levels with larger and re- tients with diabetes who otherwise have peated doses (SOR: C, extrapolated from het- good glucose control (strength of recom- erogenous and mixed cohort studies). A single steroid injection into the knee joint Evidence summary 1 week; investigators measured fructosamine causes acute Two prospective cohort studies evaluated the levels (a measure of intermediate-term hyperglycemia eff ect on glycemic control of a single gluco- glucose control) at baseline and again for 2 or 3 days corticoid injection into the knee of patients 2 weeks after injection. in patients with with controlled type 2 diabetes (glycosylated Th e injection produced hyperglycemia in diabetes who hemoglobin A1c Ͻ7.0%). Th e fi rst enrolled all participants, with peak blood glucose lev- otherwise have 9 patients with symptomatic osteoarthritis of els ranging from 251 to 430 mg/dL and time to good glucose the knee unresponsive to 3 months of nonste- peak glucose usually less than 6 hours. Fruc- control. roidal anti-infl ammatory drugs (NSAIDs).1 tosamine levels didn’t change signifi cantly. All received a 50-mg injection of methylpred- nisolone acetate after maximal aspiration of No change in glucose any joint fl uid. No changes were made to the after a single shoulder injection diabetes care regimen, including medication, Two studies evaluated the eff ect of a single diet, or exercise prescriptions. shoulder injection. One prospective cohort With self-monitoring 6 times a day dur- study included 18 patients with diabetes ing the week after the injection, 7 patients (type not specifi ed, mean A1c=7.6%).3 All showed an increase over baseline blood glu- had shoulder pain unresponsive to NSAIDs cose levels of more than 2 standard devia- for more than a month, had not changed tions; values typically rose above 300 mg/dL. diabetes medications within the preceding Peak blood sugar elevation occurred 5 to 84 2 weeks, and had not had steroid therapy hours after injection; the hyperglycemic ef- within the preceding 3 months. fect lasted for 2 or 3 days. All patients received a single injection In a second cohort study, 6 patients re- containing 35 mg methylprednisolone ac- ceived a knee injection of 1 mL Celestone etate into the anterior glenohumeral joint. Chronodose (3 mg betamethasone acetate Th ey monitored their blood glucose levels and 3 mg betamethasone sodium phos- 6 times a day for 1 week and had a fructos- phate, comparable in anti-infl ammatory amine level drawn before injection and and glucocorticoid potency to 32 mg methyl- 2 weeks afterward. Th e injection produced no prednisolone acetate).2 Patients moni- signifi cant change in mean blood glucose or tored their blood glucose 6 times a day for fructosamine levels. CONTINUED

JFPONLINE.COM VOL 59, NO 12 | DECEMBER 2010 | THE JOURNAL OF FAMILY PRACTICE 709 But repeated shoulder injections day 1 and 252Ϯ87 mg/dL on day 7; PϽ.05 raise postprandial glucose for both comparisons). Mean fasting glucose In contrast, another prospective cohort study levels didn’t change, however. followed 11 patients (8 with diabetes) who re- ceived 3 injections of 3.75 mg cortivazol (com- parable to 50 mg methylprednisolone acetate) Recommendations at 3-day intervals into 1 shoulder joint.4 In- Th e American Academy of Orthopedic Sur- vestigators checked fasting and postprandial geons treatment guidelines for osteoarthritis glucose levels before the fi rst injection and on of the knee don’t discuss possible adverse ef- post-treatment days 1, 7, and 21. fects from steroid injections.5 Th e American Th e shoulder injections elevated post- Diabetes Association makes no recommen- prandial glucose levels (from 170Ϯ60 dations regarding steroid injections in pa- mg/dL at baseline to 258Ϯ100 mg/dL on tients with diabetes. JFP

References 1. Habib GS, Bashir M, Jabbour A. Increased blood glucose levels at the shoulder joint on blood glucose levels in diabetic patients. following intra-articular injection of methylprednisolone acetate Clin Rheumatol. 2007;26:566-568. in patients with controlled diabetes and symptomatic osteoar- 4. Younes M, Neff ati F, Touzi M, et al. Systemic eff ects of epidural thritis of the knee. Ann Rheum Dis. 2008:67;1790-1791. and intra-articular glucocorticoid injections in diabetic and non- 2. Habib G, Safi a A. Th e eff ect of intra-articular injection of beta- diabetic patients. Joint Bone Spine. 2007;74:472-476. methasone acetate/betamethasone sodium phosphate on blood 5. American Academy of Orthopaedic Surgeons. Treatment glucose levels in controlled diabetic patients with symptomatic of osteoarthritis of the knee (non-arthoplasty). Available at: osteoarthritis of the knee. Clin Rheumatol. 2009:28;85-87. www.aaos.org/research/guidelines/OAKguideline.pdf. Accessed 3. Habib GS, Abu-Ahmad R. Lack of eff ect of corticosteroid injection July 2, 2009.

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CE/CME FROM THE NP EDITOR-IN-CHIEF Infl uenza The Family 2010-2011 Finishes the Dissertation s health technology A peer-reviewed journal dedicated to keeping and methodology advance, the need for continued learn- ingA and scholarly activities has driven many of us to pursue Nurse Practitioners and Physician Assistants up-to-date in clinical advanced degrees. Many are poised in various states of com- pletion, with as many reasons for being stalled in one stage as there are degree programs. practice and important trends in health care delivery. THE MANDATE D EBATE Recently, in a conversation with friends, we reminisced about © Courtesy of CDC our “all-but-dissertation” days. Laura M. Gunder, DHSc, MHE, PA-C How Can We Increase Clinicians’ Bonnie Dadig, EdD, PA-C While the pain of the process Flu Vaccination Rates? has fi nally become a mere wince Pretest probability, rapid fl u in recollection, the memory of testing, antiviral therapy, how much support we each re- vaccination—will these tools f the golden rule of medi- for Healthcare Epidemiology of see Family, page 2 >> help reduce last season’s cine is “First, do no harm,” America (SHEA), “despite Her- some experts in infectious culean efforts to increase it.” fl u-related hospitalization Clinician Reviews diseases think the major- Now, SHEA and other pro- and mortality rates? is endorsed by the hCME/CE article hInterviews with PA and ityI of clinicians are dropping the fessional medical organizations American Society ball—at least when it comes to think it may be time to take the of Endocrine PAs infl uenza vaccination. For years, gloves off (fi guratively, of course). the rate of vaccination against The organization recently pub- fl u among health care person- lished a position paper in Infec- IN THIS ISSUE NP thought leaders nel has been “unacceptably low,” tion Control and Hospital Epide- Your Turn ...... 1 in the words of Neil Fishman, in which it “endorses a see Infl uenza, page 32 miology ECG Challenge ...... 6 hIntriguing MD, President of the Society policy in which annual infl uenza vaccination is a condition of both Malpractice Chronicle ...... 7 initial and continued [health care Grand Rounds ...... 13 personnel] employment and/ Case Studies: Toxicology . .16 or professional privileges.” The recommendation applies to all Endocrine Consult ...... 21 self-assessment hMalpractice Chronicle health care providers (and other Radiology Review ...... 30 workers) in all settings, as well as students and volunteers. Infection in RA Patients . . .38 quizzes see Mandate, page 24 >> Classifi eds ...... 45

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