Should a patient with cancer undergoing chemotherapy avoid steroid injections to the knee?

Steroid Injections to the Knee During Chemotherapy

Steroid injections to the knee can be administered during chemotherapy, but their use should be limited and brief due to increased infection risk in immunosuppressed patients. 1

Key Principle for Cancer Patients

The NCCN guidelines specifically address steroid use in cancer patients undergoing chemotherapy and provide clear direction: general use of steroids should be limited in patients with cancer because steroids may increase the risk for opportunistic infections. 1 However, steroids can be used briefly when clinically necessary. 1

When Steroid Injections Are Acceptable

• For acute knee pain with effusion or inflammatory signs, a single intra-articular corticosteroid injection can be administered even during chemotherapy, as the local anti-inflammatory benefit may outweigh systemic immunosuppressive concerns. 1, 2

• The injection provides effective short-term pain relief lasting 1-12 weeks, with peak benefits at 4-6 weeks. 1, 2

• Steroid injections should be reserved for patients with persistent knee pain despite core pharmacological and non-pharmacological treatments. 1

Critical Safety Considerations During Chemotherapy

Patients receiving cancer therapy with profound immunosuppression/myelosuppression face heightened infection risks, making the timing and frequency of steroid injections particularly important. 1

Specific Precautions:

• Avoid repeat or multiple steroid injections during active chemotherapy due to cumulative immunosuppressive effects and increased opportunistic infection risk. 1

• Monitor for signs of infection closely after any intra-articular injection, as cancer patients have increased susceptibility to both superficial and deep joint infections. 1

• Coordinate with the oncology team before administering the injection, particularly in patients with neutropenia (absolute neutrophil count <1000/μL) or low CD4+ T-cell counts. 1

Timing Restrictions

Avoid corticosteroid injections within 3 months before planned knee replacement surgery due to significantly increased risk of periprosthetic joint infection. 1, 3 This recommendation applies regardless of chemotherapy status but is particularly critical in immunosuppressed patients. 3

Alternative Approaches

If the patient requires ongoing pain management during chemotherapy:

• Consider combining initial non-pharmacological treatments including physical therapy, weight reduction if applicable, and assistive devices. 1

• Oral NSAIDs or COX-2 inhibitors may be preferable to repeated injections, though renal function and cardiovascular risk must be assessed. 1

• Duloxetine can be added as an alternative or adjunct to initial treatments for persistent pain. 1

• Viscosupplementation (hyaluronic acid) injections should also be avoided within 3 months of surgery and carry similar infection concerns during chemotherapy. 3

Common Pitfalls to Avoid

• Do not use steroids routinely for antiemesis during chemotherapy cycles, as this creates prolonged systemic immunosuppression. 1 Brief steroid use (1-2 days) as premedication for highly emetogenic chemotherapy is acceptable. 1

• Do not assume that local injection avoids systemic effects - intra-articular corticosteroids do have systemic absorption and can contribute to overall immunosuppression. 1

• Do not delay necessary joint injection in a patient with severe acute knee pain and effusion simply because they are on chemotherapy - a single injection with appropriate monitoring is reasonable. 1, 2

Clinical Algorithm

1. Assess severity of knee symptoms: Is there acute pain with effusion requiring immediate intervention? 2

2. Evaluate chemotherapy regimen: Is the patient receiving high-risk myelosuppressive therapy or currently neutropenic? 1

3. If acute intervention needed AND not profoundly immunosuppressed: Administer single corticosteroid injection with close infection monitoring. 1

4. If profoundly immunosuppressed (ANC <500) or receiving high-risk chemotherapy: Defer injection if possible, use oral analgesics, or coordinate timing with nadir recovery. 1

5. Avoid repeat injections during active chemotherapy cycles - limit to single injection per treatment course. 1

6. Ensure no planned surgery within 3 months before proceeding with injection. 1, 3