Is it safe to proceed with bilateral shoulder intra-articular (IA) steroid injections in a patient with uncontrolled hypertension?

Proceed with Caution: Defer Injection Until Blood Pressure is Better Controlled

It is not advisable to proceed with bilateral shoulder intra-articular steroid injections in this patient with uncontrolled hypertension (BP 172/95 mmHg) until blood pressure is adequately managed, as corticosteroids can further elevate blood pressure and the patient requires immediate antihypertensive therapy for Grade 2 hypertension. 1, 2

Immediate Blood Pressure Management Required

This patient has Grade 2 hypertension (≥160/100 mmHg) requiring immediate pharmacological intervention before elective procedures 2:

• Confirm the elevated reading by taking at least two additional measurements using a validated device with appropriate cuff size 2
• Start immediate antihypertensive drug treatment as this BP level (172/95) qualifies for urgent pharmacological therapy 1, 2
• The initial goal should be to reduce BP by at least 20/10 mmHg, with a target of <130/80 mmHg for most adults 2, 3

Why Steroids Are Problematic in Uncontrolled Hypertension

Corticosteroids are recognized as BP-raising substances that can worsen hypertension 1:

• Systemic absorption occurs even with intra-articular injections, particularly with bilateral injections increasing total steroid dose 4
• Guidelines specifically list steroids among substances to avoid or discontinue in patients with uncontrolled hypertension 1
• The combination of pre-existing severe hypertension plus steroid-induced BP elevation creates compounded cardiovascular risk 1

Clinical Algorithm for Proceeding

Option 1 (Preferred): Defer injection and optimize BP first

• Initiate antihypertensive therapy immediately 2
• For non-Black patients: start low-dose ACE inhibitor or ARB 2
• Schedule follow-up within 2-4 weeks to reassess BP response 2
• Once BP is controlled (<140/90 mmHg minimum, ideally <130/80 mmHg), proceed with shoulder injections 1, 3

Option 2 (If pain is severe and urgent): Proceed with modified approach

• Consider unilateral injection only to minimize total steroid dose 5
• Use triamcinolone acetonide (40-80 mg) rather than methylprednisolone, as it has lower flare reaction rates and better efficacy 5
• Simultaneously initiate antihypertensive therapy on the same day 2
• Provide explicit instructions for BP monitoring every 15 minutes initially, then daily for the first week 1
• Schedule urgent follow-up within 48-72 hours to reassess BP 2

Important Caveats

Assess for secondary hypertension causes given the severity of BP elevation, particularly if this represents new-onset or resistant hypertension 1:

• Clinical clues include abrupt onset, age <30 years, or use of BP-raising substances like NSAIDs 1
• Sleep apnea is common in resistant hypertension and should be considered 1

Monitor for steroid-related complications:

• Diabetic patients may experience significant and prolonged glucose elevation lasting up to 4 weeks after a single 40 mg triamcinolone injection 4
• Steroid flare reactions occur in 4-23% of patients depending on the corticosteroid used 5

The injection itself remains effective when BP is controlled:

• Subacromial corticosteroid injections substantially decrease pain and increase shoulder range of motion in impingement syndrome 6
• Both intra-articular and subacromial approaches are safe and effective for shoulder pain when appropriately timed 7