Kenalog Joint Injection Safety in Patients on Revlimid for Multiple Myeloma
Yes, a Kenalog (triamcinolone) joint injection can be safely administered to a patient on Revlimid (lenalidomide) for multiple myeloma, but requires careful attention to infection risk and appropriate prophylactic measures.
Primary Safety Considerations
Infection Risk Management
The main concern with corticosteroid joint injections in patients on lenalidomide is the significantly elevated infection risk from immunosuppression:
Lenalidomide causes substantial immunosuppression with infection rates of 14% in standard therapy and up to 30% (grade 3-4) when combined with dexamethasone, particularly during the first three months of treatment 1
Antibiotic prophylaxis is recommended for at least the first three months of lenalidomide therapy due to increased infection rates 1
The addition of a corticosteroid joint injection temporarily compounds this immunosuppression, creating a window of heightened infection vulnerability 1
Practical Approach to Safe Administration
Before proceeding with the injection:
Ensure the patient is beyond the highest-risk period (first 3 months of lenalidomide therapy) if possible, as infection rates are highest during this window 1
Verify the patient is on appropriate antibiotic prophylaxis, particularly if they have aggressive disease, history of infectious complications, or neutropenia 1
Check current neutrophil count—avoid injection if neutropenic, as lenalidomide commonly causes myelosuppression 2, 3
At the time of injection:
Use meticulous sterile technique with strict aseptic precautions 1
Consider prophylactic antibiotics covering skin flora if not already on prophylaxis 1
Post-injection monitoring:
Counsel the patient on infection warning signs (increased joint pain, warmth, fever, systemic symptoms) 1
Lower threshold for evaluation if any concerning symptoms develop 1
Additional Considerations
Thrombotic Risk
Lenalidomide significantly increases venous thromboembolism (VTE) risk, with rates up to 70% without anticoagulation when combined with dexamethasone or chemotherapy 1
All patients on lenalidomide should already be on thromboprophylaxis (aspirin 100mg daily for low-risk patients, or LMWH/warfarin for higher-risk patients) 1, 4, 5
The corticosteroid in the joint injection does not substantially alter this baseline elevated risk, but verify the patient is on appropriate anticoagulation 1
Herpes Zoster Prophylaxis
If the patient is also receiving a proteasome inhibitor (bortezomib, carfilzomib, ixazomib) in combination with lenalidomide, they should be on acyclovir or valacyclovir prophylaxis 1, 4, 5
The additional corticosteroid exposure from the joint injection reinforces the importance of this prophylaxis 1
Common Pitfall to Avoid
Do not withhold necessary joint injections out of excessive caution—the key is appropriate risk mitigation rather than avoidance. The morbidity from untreated joint pain and reduced mobility can significantly impact quality of life in myeloma patients 1. With proper infection prophylaxis, monitoring, and patient selection (avoiding severely neutropenic patients), the procedure can be performed safely 1.
The corticosteroid dose from a single joint injection is substantially lower than the systemic dexamethasone doses these patients routinely receive as part of their myeloma regimens 1, making the incremental immunosuppressive risk manageable with appropriate precautions 1.