Osteoarthritis: Cortisone Injections and Their Alternatives

Mayo Foundation for Medical Education and Research

QUESTION: Is there a maximum number of cortisone shots that one can have in a given period -- say, one year? My rheumatologist injected me in the hip and ankle a week ago for osteoarthritis. I have had four other injections over the past six months, and he is considering giving me one or two more later this month.

ANSWER: Arthritis literally means "joint inflammation," and osteoarthritis, which results from the wearing down of the cartilage that cushions the ends of joint-forming bones, is the most common type. Osteoarthritis can affect any joint in the body -- including the hips, feet, fingers, knees and lower back.

Cortisone, a hormone naturally produced by the body, can be effective in relieving the inflammation and pain of osteoarthritis -- for several weeks or even months at a time -- when injected at higher-than-natural levels directly into the problem location. But overuse may cause troublesome side effects.

The generally accepted limit to cortisone injections is no more than about once every three months in any given joint. More frequent injections could cause injury to cartilage and bone; contribute to potential wasting of the soft tissues and muscle; and cause nerve damage, decreased resistance to infection, osteoporosis, weight gain, skin changes and cataracts.

Moreover, patients who receive frequent injections may sometimes start to manifest "hypercortisolism." This condition, also called Cushing's syndrome, has telltale signs such as a rounded face, a fatty hump between the shoulders, and pink or purple stretch marks on the skin. Other possible symptoms include muscle weakness, high blood pressure, irregular or stopped menstrual periods in women, and erectile dysfunction in men.Some of these symptoms might be tolerable if cortisone, whether by injection or taken orally, were the only available treatment for osteoarthritis. But ironically, using corticosteroids (cortisone or synthetic relatives such as prednisone or dexamethasone) is not even the option of choice in most cases. Doctors usually try less invasive treatment methods first, such as physical therapy and nonsteroidal oral medications. Physical therapy is important for improving thefunction of the joint, and nonsteroidal anti-inflammatory drugs(NSAIDs) relieve pain and fight inflammation. NSAIDs range fromover-the-counter aspirin, ibuprofen (Advil, Motrin) and naproxen sodium(Aleve) -- which are also available at higher dosages by prescription-- to others that are only available by prescription, such as piroxicam(Feldene), diclofenac (Cataflam, Voltaren) and nabumetone (Relafen).But NSAIDs have potential side effects that increase when used at highdosages for long-term treatment. They may include ringing in the ears,gastric ulcers, gastrointestinal bleeding, and liver or kidney damage.Acetaminophen (Tylenol) has been shown to be effective for peoplewith osteoarthritis who have mild-to-moderate pain, though it doesn'treduce inflammation. While this popular drug does not cause the gastricside effects associated with NSAIDs, taking more than the recommendeddosage of acetaminophen can cause liver damage, especially if thepatient habitually consumes alcohol.
Some of the discomfort of osteoarthritis can also be relievedthrough healthy-living strategies and simple self-care techniques suchas exercising regularly, controlling one's weight, applying heat,choosing appropriate footwear and practicing relaxation techniques.Even in more serious cases, when frequent cortisone injectionsappear to be the only way of relieving the pain, doctors mightreasonably question whether orthopedic referral for corrective surgerymight be a better option, assuming that the patient's overall healthwould allow it.For instance, in an osteotomy, the surgeon can reposition bonesto help correct deformities, and in an arthroplasty, the surgeonremoves the damaged joint altogether and replaces it with a plastic ormetal prosthesis. These are common procedures for hips and knees, andcan help the patient resume an active, pain-free lifestyle.Medical Edge from Mayo Clinic is an educational resource and doesn't replace regular medical care. 2006 Mayo Foundation for Medical Education and Research.
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Source: Health & Wellness

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