Annual steroid dose?

[drrosenrosen]

I've always limited total steroid doses per year to 4 for patients, and I try to count injections by other docs in this measure. I was just reviewing BCBS guidelines for ESIs, and they allow up to 6 per year. Does anybody do that many in a year? Am I being overly conservative?

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[SSdoc33]

I've always limited total steroid doses per year to 4 for patients, and I try to count injections by other docs in this measure. I was just reviewing BCBS guidelines for ESIs, and they allow up to 6 per year. Does anybody do that many in a year? Am I being ove
rly conservative?

i dont count anyone else's shots. and if a patient has knees, hips, shoudlers, and spine, ill inject everything. still waiting for this dreaded addisonian crisis which has never happened.

but i wont do 6 ESIs in a year. thats dumb

 

[callmeanesthesia]

I still try to stick to 4/ year because that’s what I feel like is standard of care, but I’ve searched the literature and found nothing to support that.

 

[jsaul]

Pcps give medrol dose packs and IM steroids multiple times a year on the same patient like its no big deal

 

[Laryngospasm]

Are you doing 80 or 40 of depo? 160 like in the old days? 4/8/12/16/20 of decadron?

 

[IHawkDO]

If I’m doing both cervical and lumbar ESI, I’ll do that every 4 months for each, so it would technically come out to a total of 6. This is a relatively small percentage of patients that I’m doing both on. Typically, if the patient has both cervical and lumbar pain, at least one tends to be more facetogenic vs. radicular. If it’s only one area (I.e: lumbar), I limit it to every 3-4 months so it never passes a total of 4 for the one area.

 

[drrosenrosen]

Are you doing 80 or 40 of depo? 160 like in the old days? 4/8/12/16/20 of decadron?

80 depo, 10 decadron. I've considered going lower, but it's a matter of getting everyone to agree on what doses we want to use and keep in stock

 

[PainMD23]

It's tough to keep up with the true steroid dosing due to the PCP's and ortho's giving medrol dosepacks and injecting joints. Nonetheless, we try our best to keep up with the total steroid load. I limit patients to less than 3 steroid injections in a 6 month period or 6 total per year. However, I've migrated most of my injections to depomedrol 20mg, or possibly 30mg (or 4-5 mg dexamethasone). There is decent data on lidocaine and possibly normal saline being just as important, if not more so, in the epidural space for radiculopathy and disc herniations. When I started practicing, I typically used 80mg depomedrol, then dropped to 40mg around 8-10 years ago, and now my dose is even lower. I've found lidocaine and using something to dilute / wash out the inflammatory milieu in the epidural space is just as important as the steroid. How many times do you see a snrb (no steroid) last 2-3 months? I have not seen a decrease in the length of relief by dropping the steroid dose. Also, we have a few patients who want a joint injection while they are having their ESI. I try to accommodate those patients by lowering the overall steroid dose in one or both injections, or changing to a visco injection, or suprascapular/ genicular / peripheral block if possible. Some of the most fragile patients we see are the older RA patients / COPD patients/ immunosuppressed patients who have received chronic year-round oral steroid dosing, so I try to be mindful of allowing adequate recovery between pulse doses of steroid for our procedures.

 

[painfree23]

It's tough to keep up with the true steroid dosing due to the PCP's and ortho's giving medrol dosepacks and injecting joints. Nonetheless, we try our best to keep up with the total steroid load. I limit patients to less than 3 steroid injections in a 6 month period or 6 total per year. However, I've migrated most of my injections to depomedrol 20mg, or possibly 30mg (or 4-5 mg dexamethasone). There is decent data on lidocaine and possibly normal saline being just as important, if not more so, in the epidural space for radiculopathy and disc herniations. When I started practicing, I typically used 80mg depomedrol, then dropped to 40mg around 8-10 years ago, and now my dose is even lower. I've found lidocaine and using something to dilute / wash out the inflammatory milieu in the epidural space is just as important as the steroid. How many times do you see a snrb (no steroid) last 2-3 months? I have not seen a decrease in the length of relief by dropping the steroid dose. Also, we have a few patients who want a joint injection while they are having their ESI. I try to accommodate those patients by lowering the overall steroid dose in one or both injections, or changing to a visco injection, or suprascapular/ genicular / peripheral block if possible. Some of the most fragile patients we see are the older RA patients / COPD patients/ immunosuppressed patients who have received chronic year-round oral steroid dosing, so I try to be mindful of allowing adequate recovery between pulse doses of steroid for our procedures.

How do you get a joint injection approved with an ESI? Most insurances say not together. Also, how often are you doing SNRB with no steroid? Why do you think those last months (physiologically)? Thanks!

 

[Ducttape]

you dont, unless you can prove and document extenuating circumstances (anticoagulation hold, for example, or long distance travelled).

 

[PainMD23]

How do you get a joint injection approved with an ESI? Most insurances say not together. Also, how often are you doing SNRB with no steroid? Why do you think those last months (physiologically)? Thanks!

Some insurances will cover with a 59 modifier, but at a reduced rate. It typically is a money loser to do both on the same date. It is more of a patient satisfaction / expectation issue than anything else.

The SNRB question, or any nerve block without steroid, is more interesting. Neural plasticity? Central nervous system reset? Does lidocaine have some anti-inflammatory effect? Placebo? More than likely several factors at play here. I don't know of much definitive data in this area.

 

[ziggyziggy]

80 depo, 10 decadron. I've considered going lower, but it's a matter of getting everyone to agree on what doses we want to use and keep in stock

Would you do ESI or any other steroid injection on a patient taking chronic oral steroids - 5 mg or 10 mg per day? If you do, do you stop oral for few days or reduce injection dosage?

 

[painfree23]

Would you do ESI or any other steroid injection on a patient taking chronic oral steroids - 5 mg or 10 mg per day? If you do, do you stop oral for few days or reduce injection dosage?

Yes

 

[Ducttape]

i dont usually stop - the oral steroids they are on are their baseline, and there is the potential you could precipitate adrenal insufficiency if you were to hold chronic steroids.

 

[DOctorJay]

What’s everyone’s limit for lifetime joint injections? say in someone whose BMI is too high for surgery and they want to just keep getting knee injections every 3-6 months?

 

[au bon pain]

What’s everyone’s limit for lifetime joint injections? say in someone whose BMI is too high for surgery and they want to just keep getting knee injections every 3-6 months?

Unless there was a specific concern in the given patient, I don’t think I would have a lifetime limit if they were legitimately continuing to get meaningful relief from them.
That said, if BMI is an issue, you could consider telling the patient that you’ll only continue them if they continue to lose weight with the goal to make a TKA possible.

Or you could recommend they start getting GLP1 injections.