Steroid injections are common procedures in primary care and outpatient settings. In most cases these injections are generally administered via an intra-articular, bursal, tendon or perineural approach with the most common indication being acute musculoskeletal pain.

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There are a range of common side effects associated with this type of injection, including infection, post-injection flare and skin changes. These are generally well communicated to patients by their treating doctor. In addition to these ‘common’ side effects there is also a theoretical risk that administering an injection may diminish the immune response to the COVID-19 vaccine. It is important to consider this risk, whether it is clinically relevant and how to communicate this to patients.

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There is no data that directly evaluates the impact of steroid injections on the efficacy of COVID-19 vaccinations. There is however some data from studies that looked at other vaccines and different routes (oral) of steroid administration. This has suggested that chronic high-dose steroids may impair vaccine-based immunity after the influenza vaccine. It should however be noted that the decrease of vaccine efficacy in this type of setting was small. Steroids given systemically in bolus format have not been demonstrated to impact vaccine efficacy.

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There are several published guidelines that make recommendations about steroid injections and the COVID-19 vaccine. Unfortunately, these provide conflicting messages. The three most widely referenced guidelines are summarised below.

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The NHS

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These guidelines emphasise that there is no evidence that a steroid injection into a joint or soft tissue will reduce the effectiveness of a COVID vaccine. They recommend that non-essential steroid injections should be delayed for two weeks after the vaccination and that a shared decision-making process is employed.1

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American Academy of Orthopaedic Surgeons (AOOS)

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The AAOS Patient Safety Committee recommends avoiding musculoskeletal corticosteroid injections for two weeks before and one week after COVID vaccine administration.2.

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American Society of Pain and Neuroscience

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These are the only guidelines that have been published in a peer-reviewed journal. They encourage clinicians to make individualised decisions, based on the patient’s needs and risk and highlight the lack of any evidence showing a negative effect on immunity from this type of procedure. The conclude that “providing interventional pain treatment concomitantly with vaccination against the coronavirus represents sound medical practice, provided that patients choosing to pursue both treatments understand that the safety and risk data”.3.

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Based on the available data and guidelines the following approach seems sensible:

1. A shared decision-making process should be undertaken that considers the patient’s past medical history, acuity of presentation/need for injection and other available treatment options.

2. A recent or pending COVID-19 vaccination is not an absolute contraindication for administering a steroid injection.

3. When possible, clinicians should consider using shorter-acting corticosteroid medications and the lowest effective dose.

4. Where possible, clinicians should try to avoid administering an injection two weeks before, and two weeks following, a COVID vaccine.

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If you are uncertain about whether your patient requires a steroid injection please feel free to contact the team at Axis Sports Medicine Specialists to discuss this further. We are operating almost exclusively by telehealth in the Level 4 environment but are running a limited number of face-to-face clinics for acute problems, including to administer steroid injections for pain-relief.

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References:

1. Oxford Rheumatology Service 2021, accessed 30 August 2021, https://www.ouh.nhs.uk/rheumatology/information/patients/documents/steroid-injection.pdf

2. Timing of Musculoskeletal Cortisone Injections and COVID Vaccine Administration AAOS 2021, accessed 30 August 2021, https://www.aaos.org/about/covid-19-information-for-our-members/guidance-for-elective-surgery/timing-of-musculoskeletal-cortisone-injections-and-covid-vaccine-administration/

3. Chakravarthy K, Strand N, Frosch A, et al. Recommendations and Guidance for Steroid Injection Therapy and COVID-19 Vaccine Administration from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2021;14:623-629. Published 2021 Mar 5. doi:10.2147/JPR.S302115

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