A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders

The appeal of intra-articular corticosteroid therapy has increased with the growing emphasis on early disease control in rheumatoid disease. The impac t on the patient's pain and stiffness is impressive and prompt. This may en courage patient compliance with longer term therapies given to slow the cou rse of the disease. The release of corticosteroid into the circulation also provides some generalised improvement. This can prove helpful during the m anagement bf flares of inflammatory disease. There is less evidence to support the use of intra-articular corticosteroid s in other inflammatory arthritides, but experience suggests that the benef its are similar. In osteoarthritis the benefits are less certain, but intra -articular therapy may prove important in patients who cannot undergo salva ge operative procedures because of intercurrent illness. The benefits of intra-articular corticosteroids may be enhanced by rest aft er the injection, or by the additional administration of agents such as rad io-colloids, rifampicin (rifampin), or osmic acid. Most controlled trial da ta have been published on knee injections, but other joints can be useful t argets for local therapy. The risks are mainly related to the discomfort of the procedure, localised pain post-injection and flushing, but most feared is septic arthritis which probably occurs in about 1 in 10 000 injections,Careful aseptic technique is the best protection. Tissue atrophy at the injection site,abnormal uteri ne bleeding, hypertension and hyperglycaemia rarely cause problems. Osteone crosis might be as much a problem with uncontrolled painful arthritis as wi th a joint rendered less symptomatic by corticosteroid injections. Intra-articular corticosteroids form an important part of the management of inflammatory joint disease and might be considered where an inflammatory e lement occurs in osteoarthritis, They may be used at any stage in the arthr itic process, but should be seen as an adjunct to other forms of symptom re lief. In patients needing multiple joint injections, systemic therapy shoul d be reviewed to see if better disease control could reduce the need for in vasive therapy.