Guidance Summary: Use of Corticosteroids for Musculoskeletal Pain during the COVID-19 Pandemic

Assembled by the AAOS Committee on Patient Safety
Updated February 3, 2021

Injectable and oral corticosteroids are commonly utilized to reduce inflammation and provide pain management in the care of patients with musculoskeletal disease. The review of indications for use of injectable and oral corticosteroids in musculoskeletal care comes from established guidelines and recommendations regarding steroid use during the pandemic and in patients with active COVID-19 disease.

Corticosteroids have been proven to aid in the treatment of COVID-19 in certain circumstances. The National Institute for Health (NIH) has issued treatment guidelines for Coronavirus Disease.1 Within these guidelines, the NIH recommends against the use of corticosteroids in patients who are not hospitalized or who are hospitalized but do not require oxygen. However, the NIH recommends that those patients with a higher disease severity receive dexamethasone in addition to remdesivir. These recommendations are largely based on data from the RECOVERY trial, where the mortality rate for those who received dexamethasone was lower in the sickest patients, but with no benefit observed in those with less disease severity.2 The World Health Organization (WHO) released recommendations echoing the support of systemic corticosteroids for “patients with severe and critical COVID-19”.3 However, these recommendations suggest “not to use corticosteroids in the treatment of patients with nonsevere COVID-19”.

There is no definitive evidence to suggest harm in treating those patients who have low severity of disease or are asymptomatic with COVID-19. The WHO states “the clinical effect of systemic corticosteroids in patients with non-severe COVID-19 remain unclear and may be studied further”. Furthermore, those patients who depend on chronic steroids should not have the medication discontinued.

The England-based National Health Service (NHS) in collaboration with the British Association of Orthopaedics (BOA) and other societies, for instance, released a clinical guide for the management of patients with musculoskeletal and rheumatic conditions on corticosteroids during the coronavirus epidemic.4 NHS’ guidance states: 

“Steroids – oral and injected – can be an important and effective treatment for some MSK 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.

Likewise, the WHO concluded that “systemic corticosteroids should not be stopped for patients with non-severe COVID-19 who are already treated with systemic corticosteroids for other reasons”.

There is some deductive reasoning without empirical evidence that steroids may increase the susceptibility to novel coronavirus (COVID-19) and prolong the infection period. It is important to note this is largely theoretical and based on evidence from studies on the influenza, SARSCoV and MERS-CoV viruses.5 Corticosteroids limit the production and damaging effect of proinflammatory cytokines released during a coronavirus infection, thereby mitigating its severe consequences such as Acute Respiratory Distress Syndrome (ARDS), Disseminated Intravascular Coagulation (DIC), hypotension, shock, and death.6 However, this may also inhibit the protective function of T cells and block B cells from making antibodies, potentially increasing plasma viral load.6,7,8,9

A recent study retrospectively reviewed patients who received corticosteroid injections during the COVID-19 pandemic to evaluate the incidence of adverse clinical outcomes related to COVID-19 infection. No adverse clinical outcomes were discovered with the conclusion “corticosteroid injections likely being low risk for the majority of patients in the setting of COVID-19”.10

In summary, orthopaedic surgeons may consider alternatives to steroids where possible during the COVID-19 Pandemic. All patients should be counselled regarding the potential immunosuppression risks of corticosteroid injections or systemic treatment. If steroids are needed, use the lowest possible dose for the shortest possible time.4,11 If patients are already taking steroids, see if their dose can be safely reduced. Many, including the NHS, recommend that steroid injections should only be given for severe symptoms, where those patients whose pain is relatively controlled “should be counselled to defer until after the pandemic subsides”.4,8,9,12 To date, no study has been published that definitively links corticosteroid injection to an increase risk of contracting COVID-19, or altering the clinical course of the infection.

Given the lack of clear evidence regarding potential harm with the use of systemic or injected corticosteroids in musculoskeletal care during the COVID-19 pandemic, robust discussion with patients regarding the potential risks and alternative treatments is critical. Particularly in those patients who are elderly or have multiple medical co-morbidities, this communication is necessary before proceeding with corticosteroid treatment to allow patients to make an informed decision.

References

  1. Therapeutic Management of Patients with COVID-19. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health, 2020.
    https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/
  2. COVID-19 Treatment Guidelines- Corticosteroids. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health, 2020.
    https://www.covid19treatmentguidelines.nih.gov/immune-basedtherapy/immunomodulators/corticosteroids/
  3. Corticosteroids for COVID-19. COVID-19: Clinical Care. World Health Organization, 2020.
    https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1
  4. National Health Service. Clinical guide for the management of patients with musculoskeletal and rheumatic conditions on corticosteroids during the coronavirus pandemic, 2020.
    https://www.rheumatology.org.uk/Portals/0/Documents/COVID19/MSK_rheumatology_corticosteroid_guidance.pdf
  5. Morgan C, Dattani R. Should I Use Steroid Injections to Treat Shoulder Pain During the COVID-19 Pandemic? Journal of Shoulder and Elbow Surgery International. 2020. PMID 32934020.
  6. Singh AK, Majumdar S, Singh R, Misra A. Role of Corticosteroid in the Management of COVID19: A Systemic Review and a Clinician’s Perspective. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020; 14(5):971-978. PMID: 32610262
  7. Theoharides TC, Conti P. Dexamethasone for COVID-19? Not so fast. Journal of Biological Regulators and Homeostatic Agents. 2020; 34(3):1241-1243. PMID: 32551464
  8. Miller D et al. Corticosteroid Injections and COVID-19 Infection Risk. Pain Medicine. 2020; 21(8):1703-1706. PMID: 32699893
  9. Hackett BA. Providing Steroid/Corticosteroid Injections Safely in the COVID-19 Environment. Journal of Radiology Nursing. 2020; 39(3): 174-175. PMID: 32368202
  10. McKean D et al. Corticosteroid Injections During the COVID-19 pandemic: Experience From a UK Centre. Bone & Joint Open. 2020; 1(9):605-611. PMID: 33215158
  11. Mattos-Sivla P et al. Pros and Cons of Corticosteroid Therapy for COVID-19 Patients. Respiratory Physiology & Neurobiology. 2020; 280:103492. PMID: 32659271
  12. Little CP et al. COVID-19: A Rethink of Corticosteroid Injection? Bone & Joint Open. 2020; 1(6):253-256. PMID: 33225297