Vol. 145 No. 2122 (2015)
The effect of intra-articular injection of Diprospan at the knee joint on the hypothalamic-pituitary-adrenal axis
- George Habib
- Rana Zahran
- Ronza Najjar
- Samih Badarny
- Adel Jabbour
- Suheil Artul
- Geries Hakim
- Hneen Jabaly-Habib
QUESTIONS UNDER STUDY: In this work we wanted to evaluate the effect of intra-articular injection (IAI) at the knee joint of 1 ml of Diprospan on the hypothalamic-pituitary-adrenal (HPA) axis.
METHODS: Consecutive patients attending the rheumatology or orthopaedic clinic with osteoarthritic knee pain not responding satisfactorily to medical and physical therapy were asked to participate in our study. After consent, patients had ultrasound-guided IAI of 1 ml of Diprospan, containing 2 mg of betamethasone sodium phosphate and 5 mg of betamethasone dipropionate. Demographic, clinical, laboratory and radiographic variables were documented. Just prior to the knee injection and 1, 2, 4 and 6 weeks later, patients had a 1-µg adrenocorticotropic hormone (ACTH) stimulation test. Secondary adrenal insufficiency (SAI) was defined as a poststimulation (30 minutes after ACTH injection) serum cortisol level of less than 18 µg/dl (~500 nmol/l) and lack of a rise of >6 µg/dl (~166 nmol/l) over the basal level in poststimulation serum cortisol.
RESULTS: Twenty patients completed the study. There were 3 male and 17 female patients, with a mean age of 58.6 ± 9.5 years. Six (30%) patients had evidence of SAI and in five of them it was seen at one time-point, mostly at week 2 after the IAI. In one patient, SAI was prolonged and observed from week 1 to week 4.
CONCLUSIONS: IAI at the knee joint of 1 ml of Diprospan was associated with a transient high rate of SAI.
- Snippe JC, Gambardella RA. Use for injections in osteoarthritis in joints and sports activity. Clin Sports Med. 2005;24:83–91.
- Gless KH, Klee HR, Vecsei P, Weber M, Haack D, Lichtwald K. Plasma concentration and systemic effect of betamethazone following intraarticular injection. Dtsch Med Wochenschr. 1981;106:704–7. German.
- Weitof T, Ronnblom L. Glucocorticoid resorption and influence on the hypothalamic-pituitary-adrenal axis after intra-articular treatment of the knee in resting and mobile patients. Ann Rheum Dis. 2006;65:955–7.
- Lazarevic MB, Skosey JL, Djordjevic-Denic G, Swedler WI, Zgradic I, Myones BL. Reduction of cortisol levels after single intra-articular and intramuscular steroid injection. Am J Med. 1995;99:370–3.
- Huppertz HI, Pfuller H. Transient suppression of endogenous cortisol production after intraarticular steroid therapy for chronic arthritis in children. J Rheumatol. 1997;24:1833–7.
- Mader R. Lavi L, Luboshitzky R. Evaluation of the pituitary-adrenal axis function following single intraarticular injection of methylprednisolonone. Arthritis Rheum. 2005;52:924–8.
- Duclos M, Guinot M, Colsy M, Merle F, Baudot C, Corcuff JB, Lebouc Y. High risk of adrenal insufficiency after a single articular steroid injection in athletes. Med Sci Sports Exerc. 2007;39:1036–43.
- Weiss S, Kisch S, Fischel B. Systemic effects of intraarticular administration of triamcinolone hexacetonide. Isr J Med Sci. 1983;19:83–4.
- Habib G, Jabbour A, Artul S. Chernin M, Hakim G. The effect of intra-articular injection of betamethasone acetate/betamethasone sodium phosphate at the knee joint on the hypothalamic-pituitary-adrenal axis: a case controlled study. J Investig Med. 2013;61:1104–7.
- Jacobs HS, Nabarro JDN. Tests of hypothalamic-pituitary-adrenal function in man. Quart J Med. 1969;152:475–91.
- Magnotti M, Shimshi M. Diagnosing adrenal insufficiency: which test is best – the 1–microg or the 250–microg cosyntropin stimulation test? Endocrin Pract. 2008;14:233–8.
- Dickstein G. The assessment of the hypothalamo-pituitary-adrenal axis in pituitary disease: are there short cuts? J Endocrinol Invest. 2003;26(7 Suppl):25–30.
- Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and therapeutic criteria committee of the American rheumatism association. Arthritis Rheum. 1986;29:1039–49.
- Dorin RL, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann Intern Med. 2003;139:194–204.
- Gandhi PG, Shah NS, Khandelwal AG, Chauhan P, Menon PS. Evaluation of low dose ACTH stimulation test in suspected secondary adrenocortical insufficiency. J Postgrad Med. 2002;48:280–2.
- Habib G, Safia A. The effect of intra-articular injection of betamethasone acetate/betamethasone sodium phosphate on blood glucose levels in controlled diabetic patients with symptomatic osteoarthritis of the knee. Clin Rheum. 2009;28:85–7.
- Husby G, Kass E, Sponqsveen KL. Comparative double-blind trial of intra-articular injections of two long-acting forms of betamethasone. Scand J Rheumatol. 1975;4:118–20.
- Habib G, Khazin F, Jabbour A, Chernin M, Badarny S, Hakim J, Artul S. Simultaneous bilateral knee injection of methylprednisolone acetate and the hypothalamic-pituitary-adrenal axis; a single-blind case-control study. J Investig Med. 2014;62:621–6.