What are the safety risks and long-term consequences of receiving intraarticular (in the joint) steroid injections, specifically triamcinolone acetonide, methylprednisolone acetate, and betamethasone acetate, at a frequency of up to 3 times per year?

Safety Risks of Intraarticular Steroid Injections

The generally accepted guideline is to limit intraarticular corticosteroid injections to no more than 3-4 injections per year in the same joint, though this recommendation is not based on strong research evidence. 1

Acute Safety Risks (Days to Weeks)

Transient Hyperglycemia

• Blood glucose levels increase significantly during days 1-3 post-injection, particularly affecting diabetic patients 1, 2, 3
• No severe adverse events such as hyperosmolar hyperglycemic state or ketoacidosis have been reported in studies 1
• Diabetic patients, especially those with suboptimal control, must monitor glucose levels for the first 3 days after injection 1, 4

Post-Injection Flare

• Temporary increase in joint pain and inflammation can occur immediately following injection 5, 2, 3
• This is a recognized adverse reaction listed in FDA drug labels for all intraarticular corticosteroids 5, 2, 3

Infection Risk

• Septic arthritis is an infrequent but serious complication when strict aseptic technique is not followed 6, 7
• In prosthetic joints, infection rate is approximately 0.6% (1 infection per 625 injections) 1
• Injections should be avoided within 3 months prior to joint replacement surgery due to increased prosthetic infection risk (increases from 0.5% to 1.0%) 1, 4, 8

Chronic Safety Risks (Months to Years)

Accelerated Cartilage Loss and Osteoarthritis Progression

• Conflicting evidence exists regarding cartilage damage with repeated injections 1, 9, 10
• One RCT comparing intraarticular corticosteroids every 3 months for 2 years versus saline showed greater progression of cartilage volume loss with corticosteroids 1
• Another RCT showed symptom improvement with no deleterious effect on cartilage volume 1
• Recent evidence suggests intraarticular corticosteroids may be associated with more MRI-assessed quantitative cartilage thickness loss than saline injections 9
• The American College of Rheumatology suggests limiting injections to 3-4 per year due to potential risks of accelerated cartilage loss and increased risk of requiring knee arthroplasty 4

Structural Joint Complications

• Aseptic necrosis of femoral and humeral heads 5, 2, 3
• Subchondral insufficiency fracture 10
• Rapid joint destruction including bone loss 10
• Charcot-like arthropathy 5, 2, 3
• Tendon rupture 5, 2, 3

Systemic Corticosteroid Effects

• Development of cushingoid state with repeated injections 5, 2, 3
• Secondary adrenocortical and pituitary unresponsiveness 5, 2, 3
• Osteoporosis and vertebral compression fractures 5, 2, 3
• Suppression of growth in pediatric patients 5, 2, 3

Duration of Safe Use at 3 Injections Per Year

High-quality studies evaluating long-term effects of repeated intraarticular injections are scarce, and there are no clear evidence-based recommendations for the appropriate number of injections from a risk-benefit perspective 1

Available Evidence on Repeated Injections

• One RCT administered intraarticular corticosteroids every 3 months for 2 years (8 total injections) and found greater cartilage volume loss compared to saline 1
• The traditional guideline of 3-4 injections per year is based on expert consensus rather than research evidence 1, 4
• An older recommendation suggested limiting injections to one every 6 weeks with no more than 3-4 in one year 6

Clinical Decision-Making for Reinjection

The shared decision to reinject a joint must consider benefits from previous injections and individualized factors including treatment alternatives, compound used, systemic treatment, and comorbidities 1

Special Populations and Contraindications

Prosthetic Joints

• Intraarticular corticosteroid injections in prosthetic joints should be avoided in routine practice 1
• Should only be considered by orthopedic surgeons after strict screening for prosthetic infection 1, 4, 8

Pregnancy

• When injecting a joint during pregnancy, consider whether the compound is safe for mother and baby 1

Patients on Anticoagulation

• Intraarticular therapy is not contraindicated in people with clotting/bleeding disorders or taking antithrombotic medications, unless bleeding risk is high 1

Post-Injection Care

Avoid overuse of injected joints for 24 hours following injection; however, immobilization is discouraged 1

• Studies show that 24-48 hour post-injection immobilization adds no benefit compared to normal activity 1