What is the best course of treatment for a 76-year-old male with advanced osteoarthritic changes at the glenohumeral joint and persistent left shoulder pain despite physical therapy and NSAIDs?

From the Guidelines

I strongly recommend proceeding with a corticosteroid injection to the left shoulder for this 76-year-old male patient with advanced glenohumeral osteoarthritis who has failed conservative management, as supported by the 2020 American College of Rheumatology guideline 1. A typical regimen would include methylprednisolone acetate 40-80mg mixed with 2-4ml of 1% lidocaine, injected into the glenohumeral joint using anatomical landmarks or ultrasound guidance. The patient should be informed that pain relief typically begins within 24-72 hours and may last 3-4 months, though results vary between individuals. Prior to injection, obtain informed consent, verify no contraindications (such as active infection, uncontrolled diabetes, or allergy to components), and ensure proper sterile technique. Following the injection, the patient should rest the shoulder for 24-48 hours and continue physical therapy to maintain range of motion and strengthen supporting muscles. Corticosteroid injections work by reducing inflammation in the joint, thereby decreasing pain and improving function. While not curative for osteoarthritis, this intervention can provide significant symptomatic relief when other conservative measures like NSAIDs and physical therapy have proven ineffective, as noted in the 2012 American College of Rheumatology recommendations 1. If the patient experiences only short-term relief, consider limiting injections to 3-4 per year to minimize potential side effects such as cartilage degradation. It's also important to consider the patient's overall health and medical history, as well as the potential risks and benefits of the injection, as discussed in the 2010 Journal of the American Academy of Orthopaedic Surgeons study 1.

Some key points to consider when administering corticosteroid injections include:

• Using proper sterile technique to minimize the risk of infection
• Monitoring the patient for potential side effects, such as changes in blood sugar levels or increased pain
• Adjusting the injection regimen as needed to achieve optimal pain relief and minimize side effects
• Continuing physical therapy and other conservative measures to maintain range of motion and strengthen supporting muscles.

Overall, the use of corticosteroid injections for the treatment of advanced glenohumeral osteoarthritis is supported by recent guidelines and studies, and can provide significant symptomatic relief for patients who have failed conservative management.

From the FDA Drug Label

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. For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient.

The patient has advanced osteoarthritic changes at the glenohumeral joint, which is a larger joint. A steroid injection of 5 mg to 15 mg of triamcinolone acetonide may be considered for this patient, with a maximum dose of 40 mg for larger areas 2.

From the Research

Treatment Options for Osteoarthritis

The patient is currently receiving physical therapy (PT) and non-steroidal anti-inflammatory drugs (NSAIDs) with no improvement. Considering the advanced osteoarthritic changes at the glenohumeral joint, the following treatment options can be explored:

• Intra-articular corticosteroid injections, which are commonly used to treat osteoarthritis-related pain 3, 4
• Intra-articular non-steroidal anti-inflammatory drug (NSAID) injections, which may be an alternative therapy to minimize systemic side effects while maintaining efficacy 5
• Other treatment options, such as topical preparations, bracing, and rehabilitation, which are likely underused in this setting 4

Safety and Efficacy of Treatment Options

The safety and efficacy of NSAIDs, including oral and intra-articular administration, have been studied extensively:

• Oral NSAIDs have been associated with gastrointestinal, cardiovascular, and renal adverse events, particularly in older patients with osteoarthritis 6
• Intra-articular NSAID injections have been found to have an excellent safety profile in small animals, large animals, and humans, although they may be associated with non-specific cartilage inflammation in healthy animals 5
• The optimal use of intra-articular NSAIDs is still to be determined, and further research is needed to fully understand their benefits and risks 5

Future Therapies for Osteoarthritis

Research is ongoing to develop new therapeutic approaches for osteoarthritis, including:

• Non-steroidal anti-inflammatory prodrugs with prolonged drug residence time within the joints, which may improve patient outcomes by reducing side effects and improving efficiency 7
• Biologic agents that target the nerve growth factor-β, which are being investigated as a potential symptomatic therapeutic option in osteoarthritis 3
• Drugs that target bone metabolism, which may have a disease-modifying effect on osteoarthritis 3