A medical doubled-edged sword

SINGAPORE — Although deemed as one of the most effective methods of joint pain relief, steroid injections may not always be prescribed by doctors as the first course of treatment.

“Anti-inflammatory medications like NSAIDS (non-steroidal anti-inflammatory drugs) are usually the first option, accompanied by rest, applying ice or heat, splinting or bracing,” said Dr Choo Chee Yong, consultant anaesthesiologist at Novena Pain Management Centre.

Oral steroids, too, may be prescribed for short-term use.

WHEN STEROID JABS ARE USED

According to Dr Choo, steroid injections are considered when the above methods prove inadequate, or if the patient shows little improvement in his functions. Known as cortisone injections, they deliver corticosteroids — synthetic hormones that are akin to the ones the adrenal gland releases to minimise inflammation — directly into the affected area.

This creates an anti-inflammatory effect including decreased redness, swelling and pain in the affected joint.

Such injections provide quicker pain relief and minimise the need for prolonged oral steroid therapy.

SIDE EFFECTS

When injected too frequently, steroids can cause both short- and long-term side effects. The former include skin shrinkage, skin lightening at the injection area and the worsening of any pre-existing joint infection. Long-term effects include elevated blood sugar levels, increased blood pressure and the thinning of bones.

While the short-term use of oral steroids does not usually lead to significant side effects, its long-term use may induce a rise in blood sugar level, an increase in blood pressure, a higher risk of osteoporosis and depression of the immune system.

Steroids can also cause emotional problems such as dramatic mood swings, which, in severe cases, may lead to violence, depression, paranoia or impaired judgment.

“The symptoms may emerge a short while after the commencement of therapy and may range from euphoria, mood swings, personality changes, depression to psychosis,” said Dr Choo.

Between oral and injectable steroids, the physical and mental side effects are more frequently seen in patients who are on the oral course.

Injectable steroids — because they are administered by doctors and are thus, better controlled — minimise the problems associated with prolonged oral steroid therapy.

“If steroid injections are limited to three or four times a year, it is very unlikely that these side effects will develop,” said Dr Choo, who added that the duration for oral steroids differs from patient to patient.

TO INJECT OR NOT TO INJECT?

As steroid injections are invasive by nature, Dr Choo advised that they might not be suitable for all patients. For example, patients with skin infection overlying the joint, a blood-clotting disorder or suspected joint infection should not receive steroid injections.

In such cases, the injection could significantly worsen the patient’s condition. In addition, the imprecise injection of steroids into the joint may also cause new complications (see box story).

Despite the side effects, there is a place for steroid medications when it comes to treating joint pain. “Steroid medications are a double-edged sword as they could have significant side effects. When used in a supervised manner by a medical practitioner, steroids can be safe and effective for treating inflammatory and painful conditions,” said Dr Choo.

The key is to ensure that any use of steroids to treat medical conditions is carried out under proper medical supervision and to be wary of steroid use over an extended period of time.