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Timing of Musculoskeletal Cortisone Injections and COVID Vaccine Administration

AAOS Patient Safety Committee
3/9/2021

The AAOS Patient Safety Committee recommends avoiding musculoskeletal corticosteroid injections for two weeks before and one week after COVID vaccine administration.

Musculoskeletal corticosteroid injections are common procedures which are most often performed in an elective, outpatient setting. These can include intra-articular, bursal, tendon, and neuraxial injections. Currently there is no direct evidence of the impact of corticosteroid injections on vaccine efficacy.

Corticosteroid injections have been shown to cause hypothalamic-pituitary-adrenal suppression. Increased risk of influenza infection has been associated with corticosteroids. It is unknown if corticosteroid injections could result in decreased immunogenicity which could reduce vaccine efficacy. The majority of musculoskeletal cortisone injections are elective procedures that can be safely postponed or rescheduled. Given the potential risk of diminished vaccine benefit, caution is appropriate.

When possible, surgeons should consider using shorter-acting corticosteroid medications and the lowest effective dose.

Surgeons should have an informed discussion with each patient regarding the potential risk of decreased vaccine effectiveness. Special circumstances need to be considered. There will be appropriate exceptions to these guidelines as some patients will choose to proceed with the injection despite potential risk. Surgeons should engage each patient in shared decision-making to ensure appropriate informed consent.

These recommendations are based on the best currently available clinical evidence and may be subject to update as more evidence is available.

References:

  1. Manchikanti L, Kosanovic R, Vanaparthy R, Vangala BP, Soin A, Sachdeva H, Shah S, Knezevic NN, Hirsch JA. Steroid Distancing in Interventional Pain Management During COVID-19 and Beyond: Safe, Effective and Practical Approach. Pain Physician. 2020 Aug;23(4S):S319-S350. PMID: 32942792.
  2. Habib G, Jabbour A, Salman J, Hakim G, Haddad H. The effect of epidural methylprednisolone acetate injection on the hypothalamic-pituitary-adrenal axis. J Clin Anesth. 2013 Dec;25(8):629-33. doi: 10.1016/j.jclinane.2013.07.002. Epub 2013 Aug 27. PMID: 23988802.
  3. Sytsma TT, Greenlund LK, Greenlund LS. Joint Corticosteroid Injection Associated With Increased Influenza Risk. Mayo Clin Proc Innov Qual Outcomes. 2018 Mar 20;2(2):194-198. doi: 10.1016/j.mayocpiqo.2018.01.005. PMID: 30225449; PMCID: PMC6124339.
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  5. U.S. Centers for Disease Control and Prevention. How CDC is making COVID-19 vaccine recommendations. Updated 3/3/2021, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations-process.html