Sunday, July 3, 2016

Steroid injections, a success?

It has been common medical practice for years, to use steroid injections throughout the body to help control inflammation and pain.  I have many patients who constantly ask me if steroid injections are just a "bandaid" for their pain, or if the steroid injection is actually going to help treat their pain long term.

The Treatment Score = the net treatment benefit for the patient.

The knee is a very common location of pain and osteoarthritis.  It makes sense, then, that this would be the first location that I would chose to research for the efficacy of steroid injections.  There have been many articles published that relate to knee osteoarthritis and the efficacy of steroid injections.  After I looked up many articles, I realized that it would be almost impossible to compare more than one article.  One reason for this is that, in order for people to study a particular disease, and get the outcomes that they desire, they have so many different inclusion criteria for participants.  Some studies cut off participants based on age, some are based on perceived level of pain, and others are based on MRI findings.  No of these studies can be compared to the other, as the patient populations all tend to be different.  In medicine, we cannot assume that just because one treatment works for one particular group of people, that it will have the same effects on another group.

I decided to pick a study that used pain as the basis for their inclusion criteria.  This study also measured synovial tissue volume, which is a direct measurement of inflammation in the joint.  What I found was actually incredible!



The part of this study that amazes me, is that it had to be divided into "responders" and "non responders" due to the high (71%) rate of people who relapsed within 6 months.  Above is the score for the non responders, and below is the score for the responders.  Despite the poor response to steroid injections of the majority of the participants, the authors still concluded that steroid injections are a good treatment option for patients with knee osteoarthritis.  This conclusion actually blows my mind!  As you can see above, the main statistic for the non responders is a zero.  I had to increase that score to a 1, just so that it would register in our treatment calculator and get a grade.  But, after 6 months, most of the people in the study had increased pain as compared to baseline.  I'd say this is a good enough reason for a low grade.

Below is the score for the responders (23% of participants).  This score was increased due to a decrease in pain and a decrease in inflammation after 6 months.





As you can see above, the treatment grade overall for steroid injections to the knee is extremely low. Admittedly, I only graded the injection at the 6 month follow up point.  Had I used the 1 week point of follow up, the score definitely would have been higher, as people did respond quickly to the injection.  But this is not what I was interested in.  Though some people are interested in short term relief of painful symptoms, most patients at least want to know long term outcomes of treatment.

Though patients did have decreased knee pain after a week, most patients had increased pain from baseline after 6 months.  I would not call this a successful treatment.  Additionally, in this study, higher doses of steroids were used than in a typical practice, which may make the results appear even better than they may have if using therapeutic doses of steroids and not supratherapeutic dosing.

As you can see, results like this make it difficult to actually understand which treatments are beneficial to patients.  Knowing this information, I will personally use steroids more judiciously.  I am not saying that they don't have a place (like if someone needs immediate, short term, pain relief). I am just saying that we cannot rely just on what has been taught to us for years, and we, as physicians, need to more fully understand the actual efficacy of each treatment we prescribe to our patients.  It is our hopes, through Treatment Scores, that we can help increase both patient and physician knowledge in this way and positively affect the practice of medicine. (See the disclaimers below.)

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