Every year, the majority of physicians need to attend continuing education courses. Sometimes these are online or via written materials, while others are seminars. This year I am on my second course, because unfortunately not all work qualifies for credits. The last course was extremely educational, but was sponsored by a medical corporation and therefore did not qualify for credit.
This week I am again gone from the office attending a conference. One of my goals is always to bring back some pearls to my practice. The first subject I’ve been learning more about is steroids and their role in a patient management program.
Steroids and Their Safety
The main question is whether the corticosteroids that are used in pain injections are safe for the patient. The answer of course is complicated. In a pain practice, corticosteroids are used to bring down inflammation. There are many different types of steroids, as those used for pain control are different from steroids used to build muscles or control hormones. Corticosteroids not only decrease inflammation as well as pain, but can also do many other things in the body. The problems they caused were discovered mainly due to their use for other conditions.
Conditions like asthma, lung disease, and rheumatoid arthritis were all previously treated for years with oral, injected and IV steroids. From their use, we slowly learned some of the issues with these medications. The most obvious was the problems with blood sugars and diabetes. Steroids can make blood sugars elevated, usually for only several days when used in the spine or joints, but sometimes for several weeks. Corticosteroids can also alter the function of the balance of normal hormones in the body, causing problems with blood pressure, emotions, and female or male hormone balance.
One of the biggest worries of with the use of steroids is the cumulative effects like bone loss. Osteopenia and osteoporosis are the bone loss problems that can be increased over time with the use of corticosteroids. As people age, the natural function of bone growth changes and many people develop bone loss. The use of corticosteroids can increase the rate of bone loss. Now it is known that there is a yearly amount of steroid-type injections to try to stay below. That is between 4 and 6 shots total.
Too much steroid can increase bone loss and make osteoporosis worse. The problem with osteoporosis is that bone fractures can become more common. It can lead to problems like broken hips from a fall to spontaneous vertebral body fractures in the spine. The vertebral compression fractures can be fairly painful and cause spinal deformities.
The bottom line on the use corticosteroids in the management of pain is that they are not fully safe, but they can be used as part of an overall strategy to manage painful conditions. The total amount of steroids should be monitored, and if a person has had a number of incidents of exposure to this medication, then monitoring for side effects is necessary. If one is a diabetic, blood sugars should be watched whenever using these medications.
Most people may need to be watched for bone loss, and then bone density monitoring is necessary. Osteoporosis is a silent disease with only 25 percent of those who have it being aware of the problem and seeking treatment. Since pain physicians often use the medication in their injections, it should be a routine concern to monitor patients who are receiving shots. If you are at risk for bone loss, make sure that your doctors test you for it, it can even happen to young and seemingly healthy individuals.
That’s all for now, off to another conference lecture!
Dr. Cohn