Steroid injections and COVID-19 – Updated Guidance November 2020

13 Nov 2020

Joint response of the College of Podiatry and the Faculty of Podiatric Medicine of the Royal College of Physicians and Surgeons of Glasgow:  Updated guidance on the safety of steroids injected as part of podiatric procedures during the current COVID-19 virus pandemic.

Introduction

The College of Podiatry and the Faculty of Podiatric Medicine of the Royal College of Physicians and Surgeons of Glasgow have reviewed their guidance on the use of corticosteroid injections in light of experience during the COVID-19 pandemic.   This joint statement (published on the 13th November 2020) provides updated details on our guidance and recommendations.

Steroid use is common in podiatric procedures with the aim of easing pain, increasing mobility and quality of life. Duration of effect is variable but can provide several months of benefit.  It is still the case that current evidence does not yet allow us to fully quantify the risks, should a patient receiving steroid injections come into contact with COVID-19 during the period of associated immunosuppression. As a result of the long quarantine period of an average of 14 days, there is a risk that asymptomatic patients who are carrying the virus could undergo corticosteroid injection as part of a podiatric treatment whilst infected by, but asymptomatic of, Covid-19, potentially putting them at increased risk of an adverse outcome from the virus. This risk factor may be more marked in higher risk patient groups, notably the elderly and those with comorbidities, whose underlying pathology / pathologies are associated with higher mortality rates.

Moreover, podiatrists must also be mindful of the risk of undertaking podiatric procedures in a hospital setting, where they, as staff,  may be at risk of being exposed to potentially infected patients.

Use of steroids: possible impact in relation to COVID-19

The current WHO guidance ¹ for the management of severe acute respiratory infection in patients with COVID-19 is to avoid the routine use of systemic corticosteroids unless these are strongly  indicated for another reason. This is because steroids have been associated with an increased risk for mortality in patients with influenza and delayed viral clearance in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection.  Although systemic steroids were widely used in the management of severe acute respiratory syndrome (SARS), there was no good evidence of their  benefit, and there was persuasive evidence of adverse short-and long-term harm ² . A recent study of patients with COVID in China reports that patients receiving corticosteroids did not have an effect on mortality, but rather delayed viral clearance ³.

Advice

While our previous recommendations still stand, we do, however, recommend that a risk benefit ratio is also assessed in the context of the local prevalence of the COVID-19 virus at that point in time. 

Clearly, corticosteroid injections should not be undertaken in individuals with active COVID-19 infections.  However, there is still potential for harm to individuals who may be incubating or later develop COVID-19.

Long acting, usually insoluble steroid formulations are frequently used in procedures to manage pain.  To put this into context, Triamcinolone Acetonide 40mg is equivalent to ten times the normal daily physiological steroid production. Epidural steroids have been shown to cause a variable degree of adrenal suppression for at least some weeks ⁴. The potential impact of this immunological suppression in a patient incubating COVID at the time or in the future is still largely unknown.

On that basis, and the close monitoring of national guidance, as the pandemic continues to present a challenge, we recommend the following advice:

• Maintain an awareness of the risk of using corticosteroid injections during the COVID-19 pandemic.  Even in the absence of definitive evidence, steroids do have an immuno-suppressant effect.
• Undertake careful assessment of the risk: benefit ratio. Where possible use alternatives that are safe and effective. PDF of the article published last month attached.
• Assess patients’ COVID-19 status.  A simple questionnaire would suffice that covers the following areas.
  • Do you have any of the following symptoms:
    • New, continuous cough (meaning: coughing for longer than an hour, or three or more coughing episodes in 24 hours)
    • High temperature or fever (ie: forehead skin temperature of >37C)
    • Loss of, or change in, sense of smell or taste
    • Have you tested positive for COVID-19 in the last 7 days or, are you waiting for a COVID-19 test or the results of a recent Covid-19 test?
    • Do you live, or have you been in contact with someone who has either tested positive for COVID-19 or has shown thesymptoms of COVID-19 in the last 14 days?
    • Were you ever asked to isolate for any reason?
• Check the patient’s temperature prior to treatment (ie: forehead skin temperature of >37C).
• Assess steroid risk using a validated tool, such as that devised by the American Society of Interventional Pain Physicians (see below).

Although steroid injections are now widely used in all NHS and private clinics with the appropriate risk benefit assessments in place, it is important to note that in many cases the alternatives are effective.

Following our earlier guidance, we would advise that:

• The clinical decision to administer corticosteroid injections should take into account the current COVID-19 situation in that region.
• All reasonable non-injection pain management measures should be explored before injections are started or resumed.
• The decision to resume injections should be based on a balance of risks and benefits for individual patients.
• Protective measures and use of PPE should follow local protocols, to minimise the risk of Covid-19  to patients and staff.
• During the Covid-19 pandemic: only administer corticosteroid injections:
  • to patients who test negative to Covid-19
  • following all recommended protocols to prevent cross-infection and potential exposure of staff and patients to Covid-19 
  • to patients where no other therapy will help relieve pain, increase mobility and improve the patient’s quality of life