Do corticosteroid (CS) injections accelerate arthritis?

Do Steroid Injections Accelerate Arthritis?

Corticosteroid injections may potentially contribute to cartilage loss in some patients, but this finding is not clinically significant as it has not been associated with worsening pain, function, or other radiographic features. 1

Evidence on Steroid Injections and Arthritis Progression

Benefits of Intra-articular Corticosteroid Injections

• Strongly recommended for knee and hip osteoarthritis (OA) by the American College of Rheumatology (ACR) 1
• Conditionally recommended for hand OA 1
• Provide short-term pain relief and functional improvement 1
• Particularly effective for flares of knee pain, especially when accompanied by effusion 1

Concerns About Cartilage Effects

• A recent study raised concerns that specific steroid preparations or frequent injections may contribute to cartilage loss 1
• However, the ACR Voting Panel was uncertain about the clinical significance of this finding 1
• Importantly, observed cartilage thickness changes were not associated with:
  • Worsening pain
  • Decreased function
  • Other negative radiographic features

Recent Research on Long-Term Effects

• More recent research (2019) suggests potential adverse joint findings after intra-articular corticosteroid injections, including 2:
  • Accelerated OA progression
  • Subchondral insufficiency fracture
  • Complications of osteonecrosis
  • Rapid joint destruction with bone loss
• A 2020 study using data from the Osteoarthritis Initiative found that patients receiving corticosteroid injections had a higher risk of requiring knee arthroplasty (hazard ratio 1.57) 3
• Each injection increased the absolute risk of arthroplasty by 9.4% at nine years' follow-up 3

Clinical Recommendations

Appropriate Use of Corticosteroid Injections

• Use for short-term symptom relief rather than as a disease-modifying treatment 1
• Consider ultrasound guidance for accuracy, particularly for hip injections (strongly recommended) 1
• Corticosteroid injections are conditionally recommended over other forms of intra-articular injection (including hyaluronic acid) due to higher quality evidence for efficacy 1

Precautions and Limitations

• Effects are relatively short-lived (typically weeks rather than months) 1, 4
• Repeated injections should be limited due to potential negative effects on joint structure 2, 3
• Consider conservative approach in patients with, or at risk of developing, symptomatic OA of the knee 3
• Contraindications include presence of intra-articular foreign body, active infection, fracture, and planned joint replacement surgery within 3 months 5

Balancing Risks and Benefits

When considering corticosteroid injections for arthritis:

1. Use as part of a comprehensive treatment plan, not as the sole therapy
2. Limit frequency to minimize potential cartilage effects
3. Monitor for clinical response rather than focusing on radiographic changes
4. Consider the patient's overall disease severity and other treatment options

While there is evidence suggesting potential acceleration of joint deterioration with repeated use, the short-term benefits for pain relief and function may outweigh these risks in appropriate patients, particularly when other treatment options have failed.