Injectable and oral corticosteroids are commonly used to reduce inflammation and manage pain in patients with musculoskeletal disease. Concerns regarding the use of injectable and oral corticosteroids in musculoskeletal care come from guidelines for systemic steroid use in patients being treated for active COVID-19 disease, such as those from the National Institutes of Health (NIH). Within the guidelines, the NIH provides evidence-based recommendations “against the routine use of systemic corticosteroids for the treatment of mechanically ventilated patients with COVID-19 without acute respiratory distress syndrome (ARDS).” For “mechanically ventilated adults with COVID-19 and ARDS, there are insufficient data to recommend either for or against corticosteroid therapy in the absence of another indication.”
A recent study suggests that in patients who require supplemental oxygen or mechanical ventilation, one steroid, dexamethasone, may reduce the death rate related to COVID-19 illness. Further studies will be helpful to confirm that finding. The World Health Organization recommendations currently state, “Do not routinely give systemic corticosteroids for treatment of viral pneumonia outside clinical trials.”
There is little definitive evidence to suggest harm in treating asymptomatic patients whose COVID-19 status may be unknown or who subsequently test positive for COVID-19 with corticosteroids for musculoskeletal care. Specifically, no published literature addresses harms related to intra-articular steroid injections in the setting of the COVID-19 pandemic. However, given the lack of evidence for or against the use of intra-articular steroid injections, caution is recommended.
The England-based National Health Service (NHS), for instance, released a clinical guide for the management of patients with musculoskeletal and rheumatic conditions on corticosteroids during the coronavirus epidemic. NHS’ guidance states: “Steroids—oral and injected—can be an important and effective treatment for some [musculoskeletal] conditions, particularly rheumatic conditions, some types of arthritis, and joint pain. Sometimes these can be lifesaving. Stopping steroids suddenly can be dangerous, and patients should only do so under clinical supervision. There is concern that steroids can increase risk [of increasing susceptibility to] the novel coronavirus (COVID-19) [by affecting the immune system]. Because of this, we should consider alternatives to steroids where possible. If steroids are needed, use the lowest possible dose for the shortest possible time. If people are already taking steroids, see if their dose can be safely reduced. And only give steroid injections for severe symptoms and where there are no other options.”
Given the lack of clear evidence regarding potential harm with the use of corticosteroids in musculoskeletal care during the COVID-19 pandemic, robust discussions with patients regarding potential risks and alternative treatments are critical. Particularly in patients who are elderly or have multiple medical comorbidities, communication is necessary before proceeding with corticosteroid treatment to allow patients to make informed decisions. As the evidence evolves, AAOS will continue to update its membership on the most current findings.
This article was assembled by the AAOS Committee on Patient Safety.
National Health Service: Management of patients with musculoskeletal and rheumatic conditions on corticosteroids. Available at: www.rheumatology.org.uk/Portals/0/Documents/COVID-19/MSK_rheumatology_corticosteroid_guidance.pdf. Accessed July 8, 2020.
National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. Available at: www.covid19treatmentguidelines.nih.gov. Accessed July 8, 2020.
World Health Organization: Clinical Management of Severe Acute Respiratory Infection (SARI) When Novel Coronavirus Infection Is Suspected. Available at: www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf. Accessed July 8, 2020.
Horby P, Lim WS, Emberson JR, et al: Dexamethasone in hospitalized patients with Covid-19—preliminary report. N Engl J Med 2020 [Epub ahead of print]