Could Corticosteroid Injections Interact With The COVID-19 Vaccine?

Each spring, I welcome new students beginning their clinical training in podiatric medicine. Often, I'll ask students to develop their own treatment plans for their patients. Student doctors are anxious to perform procedures and often suggest administering corticosteroid injections for conditions including hallux limitus, plantar fasciitis, neuromas, and ankle osteoarthritis. Corticosteroids can prove beneficial in decreasing inflammation and pain in many common podiatric conditions. I typically will support a sound treatment plan from my student doctors.  However, I have been more cautious as of late when deciding to proceed with glucocorticoid steroid injections, as more of my patients receive COVID-19 vaccinations.

In my observation, there is no clinical evidence suggesting that corticosteroid injections impair the COVID-19 vaccine efficacy; however, small and limited studies suggest that one single corticoid steroid intramuscular injection affects various vaccines' effectiveness, including the influenza vaccine.¹

Hypothalamic-pituitary-adrenal (HPA) axis suppression can occur following a single epidural or intraarticular corticosteroid injection.¹ Moreover, it is possible that after a musculoskeletal injection, systemic absorption of glucocorticoids may take place. The degree of steroid absorption depends on the size of the joint injected, the dose, and the strength of the corticosteroid used.¹ Many studies have shown that HPA axis depression may be present for up to 14 days after a musculoskeletal steroid injection. In some cases, the HPA axis does not return to normal levels until 28 days after a steroid injection.¹

The timing of the HPA axis suppression following a musculoskeletal steroid injection and the reported peak efficacy of the Pfizer-BioNTech and Moderna vaccines has prompted new recommendations from the American Academy of Orthopaedic Surgeons (AAOS).² The AAOS recommends avoiding musculoskeletal corticosteroid injections for two weeks before and one week after COVID-19 vaccine administration.²

Again, there is no evidence that a corticosteroid injection could result in decreased immunogenicity of the COVID-19 vaccine. However, it is prudent to document the date(s) your patients received their COVID-19 vaccine dose(s). If indicated, please discuss these evolving potential risks of that steroid injection with recently vaccinated patients and consider obtaining signatures of informed consent regarding your discussion.

Dr. Robinson is the Chair of and an Assistant Professor in the Department of Medicine at the Temple University School of Podiatric Medicine. She is a Diplomate of the American Board of Podiatric Medicine.

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References

1. Abdul AJ, Ghai B, Bansal D, Sachdeva N, Bhansali A, Dhatt SS. Hypothalamic pituitary adrenocortical axis suppression following a single epidural injection of methylprednisolone acetate. Pain Physician. 2017;20(7):E991-E1001.

2. AAOS Committee on Patient Safety. Guidance Summary: Use of corticosteroids for musculoskeletal pain during the COVID-19 pandemic. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/patient-safety/covid-19/steroid-injections-and-covid-19-guidance-document.pdf  . Accessed May 13, 2021.