What is the appropriate management for a 76-year-old male patient with advanced osteoarthritic changes at the glenohumeral (shoulder) joint presenting with left shoulder pain and requesting a steroid injection?

From the Guidelines

I strongly recommend against proceeding with a corticosteroid injection for this 76-year-old male with left shoulder pain due to advanced glenohumeral osteoarthritis, as the current evidence does not support its use for this condition, and instead consider alternative treatments such as physical therapy, activity modification, and oral analgesics. The most recent and highest quality study available, 1, states that there is no evidence to support or refute the use of intra-articular corticosteroid injection for the treatment of glenohumeral osteoarthritis, and therefore, it is not recommended.

Alternative Treatment Options

Consider the following alternative treatment options:

• Physical therapy to improve range of motion and strength
• Activity modification to reduce stress on the joint
• Oral analgesics, such as paracetamol or topical non-steroidal anti-inflammatory drugs (NSAIDs), for pain relief, as recommended by 1
• Orthopedic consultation for surgical options if symptoms remain severe despite conservative measures

Important Considerations

Before proceeding with any treatment, verify that there are no contraindications, such as active infection, uncontrolled diabetes, or allergies to the medications. The patient should be informed that while these alternative treatments may provide significant pain relief, they are not curative for the underlying osteoarthritis.

Treatment Approach

A comprehensive treatment approach should be taken, considering the patient's individual needs, risk factors, and preferences. The treatment options should be arranged in the order of core treatments, such as physical therapy and activity modification, followed by pharmacological treatments, such as oral analgesics, and finally, surgical options, as recommended by 1.

From the FDA Drug Label

For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient. Single injections into several joints, up to a total of 80 mg, have been given. LOCAL Intra-articular administration: A single local injection of triamcinolone acetonide is frequently sufficient, but several injections may be needed for adequate relief of symptoms. Initial dose: 2. 5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated.

The patient has advanced osteoarthritic changes at the glenohumeral joint. The recommended dose for intra-articular administration of triamcinolone acetonide is 5 mg to 15 mg for larger joints. Considering the patient's condition, a dose of 40 mg could be used, but it is essential to start with a lower dose and adjust according to the patient's response.

• Key considerations:
  • Intra-articular injection technique should be followed.
  • Aseptic technique is mandatory.
  • Local anesthetic may be desirable.
  • Aspiration of synovial fluid may be necessary.
  • Risk of infection and septic arthritis should be considered.
  • Osteoporosis and bone growth inhibition are potential risks.
  • Neuro-psychiatric and musculoskeletal adverse reactions are possible. 2

From the Research

Treatment Options for Osteoarthritis

• The primary goals of current osteoarthritis (OA) therapy are centered on controlling pain, improving or preserving joint function and mobility, and improving health-related quality of life 3.
• Current treatment options for OA consist of both non-pharmacological and pharmacological modalities, including patient education, physical/occupational therapy, acetaminophen, nonspecific NSAIDs, and COX-2 specific inhibitors 3.
• For patients with severe OA not responsive to medical treatment, nonsurgical interventions such as viscosupplements and injectable compounds, or surgical interventions are two likely options 3.

Pharmacological Treatment for Osteoarthritis

• Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids are common pharmacologic treatments for OA, with varying levels of efficacy and safety 4.
• NSAIDs have been associated with wide-ranging adverse events affecting the gastrointestinal, cardiovascular, and renal systems, particularly in older patients with OA 5.
• Intra-articular (IA) NSAIDs may be an alternative therapy, possibly minimizing systemic side effects while maintaining efficacy, with a single dose providing less total systemic and synovial exposure compared to a one-week course of oral NSAIDs 6.

Intra-Articular Corticosteroid Injections

• IA corticosteroid injections are a common treatment for OA-related pain, but repeat injections may cause cartilage degeneration 6.
• IA NSAIDs have similar efficacy to IA corticosteroids in treating OA-related pain, and may be used to augment IA corticosteroid injections or as an alternative in patients at high risk for corticosteroid-related adverse events 6.

New Therapeutic Approaches

• Developing new therapeutic approaches based on anti-inflammatory prodrugs with prolonged drug residence time within the joints appears as a promising strategy in OA, aiming to decrease side effects and improve efficiency of locally released drugs 7.
• Charge-based targeted approaches, such as using a positively charged quaternary ammonium to target the negative-fixed charge density in cartilage, may extend the residence time of NSAID within the cartilaginous tissues 7.