An Emerging Protocol For Safer Corticosteroid Injections During The COVID-19 Pandemic

By Troy Boffeli, DPM, FACFAS and Zachary Lubek, DPM

Since the vast spread of COVID-19 and the associated concern of contracting the virus, many patients and physicians alike have taken significant measures to limit potential exposure. From a physician standpoint, we now need to strongly consider which patients we should see in clinic. Yet we still have the task of providing patients with pain relief for musculoskeletal complaints. This is even more important in the midst of delaying or preventing the need for elective surgeries. 

When other conservative measures fail, providers often use steroid injections as an effective second-tier modality in treating various pathologies from arthritic joint pain to plantar fasciitis and neuromas. However, it is also well-documented that corticosteroids may have the adverse side effect of dulling the immune response and placing certain individuals at higher risk of contracting an illness.¹ 

So how do we balance giving injections to patients whose symptoms warrant this treatment with the concern of placing individuals at a supposed higher risk of developing COVID-19? 

First, concerns for a decreased immune response relate more to high-dose, long-term use of systemic steroids with little mention in the literature of similar problems with locally injected steroids. One may employ additional measures to reduce immune suppression when giving steroid injections. These additional measures often align with the typical steroid injection in the foot or ankle, and include: 

• the use of locally-acting steroids (versus systemic administration); 
• low dose/short-acting preparations (dexamethasone is short acting and 10 mg of Kenalog (triamcinolone acetonide) is a low dose); and
• utilizing a one-time or staggered dose (as we typically do). 

Second, appropriately screening patients can help reduce such risk even further. 

Our goal is to develop an efficient risk screening and safe injection protocol, which would allow schedulers, nursing staff and providers to decide which patients they can see for face-to-face visits involving corticosteroid injections.

We currently utilize recommendations from the American Society of Interventional Pain Physicians (ASIPP) and their Risk Stratification Table to screen patients along with the Safe Injection Protocol Flow Chart (click here for chart) to help make the final decision before administering a steroid injection amid the COVID-19 pandemic.²

This allows the examiner to assign a numerical risk number and associated risk category based on pre-identified risk factors (i.e. age, lung and heart history, body mass index (BMI), diabetes control, renal and hepatic history and immune history). One can obtain this information through both patient questioning and chart review. 

We can reasonably deduce that if a patient is under 65 years of age, has a body mass index (BMI) less than 30 and has no history of cardiopulmonary, renal, hepatic or immune deficiency, he or she would be a low-risk patient. Patients that would warrant risk stratification are those over the age of 60 with history of asthma or chronic obstructive pulmonary disease (COPD), hypertension, coronary artery disease, BMI greater than 30, poorly controlled diabetes, renal or hepatic insufficiency or presence of an immunocompromised state like chronic steroid use, human immunodeficiency virus (HIV), etc. These patients would likely fall into a moderate to high risk category.

The assigned risk category is intended to help determine a patient’s risk of having a negative or worsened immune response if he or she contracts the COVID-19 virus. One can then consider the patient’s risk category and the Safe Injection Protocol Flow Chart to decide whether or not to proceed with an injection.

The final step is to document that the patient is at low to moderate risk, is currently asymptomatic from a COVID-19 standpoint, has exhausted other conservative measures and that the goal of the injection is to delay the need for surgery. 

Following the above protocol could allow providers a pathway to properly evaluate patients, stratify patient risk and document clinical decision-making, which is more important than ever in the current pandemic climate.

Dr. Boffeli is the Foot and Ankle Surgical Residency Program Director and Department Chair at Regions Hospital/HealthPartners Medical Group in St. Paul, Minn.

Dr. Lubek is a second-year resident in the Foot and Ankle Surgical Residency Program at Regions Hospital/HealthPartners Medical Group in St. Paul, Minn.

References

1. Chatham WW. Glucocorticoid effects on the immune system. UpToDate. Available at: https://www.uptodate.com/contents/glucocorticoid-effects-on-the-immune-system . Updated March 15, 2019. Accessed May 13, 2020.
2. American Society of Interventional Pain Physicians. ASIPP risk stratification of patients presenting for interventional pain procedures: decreasing morbidity of COVID-19. Available at: https://files.constantcontact.com/be15115b001/7589e1ab-5864-4bb9-9b07-88cb21ff899a.pdf . Accessed May 13, 2020.