key: cord-0917138-uo9gdc7w authors: Powelson, Ian; Kaufmann, Robert A.; Chida, Natasha M.; Shores, Jaimie T. title: A New Consideration for Corticosteroid Injections (CSI): SARS-CoV-2 Vaccination. date: 2021-07-16 journal: J Hand Surg Am DOI: 10.1016/j.jhsa.2021.07.002 sha: a99d94831f971f50db54abc78be936152329880b doc_id: 917138 cord_uid: uo9gdc7w Corticosteroid injection (CSI) is a commonly used tool in hand surgery that is often given little consideration as a potential detriment to vaccination efficacy. The authors discuss guidelines issued by relevant societies for the timing of CSI around the SARS-CoV-2 vaccination period and the evidence used to support them. Ultimately, providers and patients should be adequately educated on the theoretical risks and benefits before proceeding with CSI immediately before, during, or immediately after COVID-19 vaccination. Abstract: Corticosteroid injection (CSI) is a commonly used tool in hand surgery that is 7 often given little consideration as a potential detriment to vaccination efficacy. The 8 authors discuss guidelines issued by relevant societies for the timing of CSI around the 9 SARS-CoV-2 vaccination period and the evidence used to support them. Ultimately, 10 providers and patients should be adequately educated on the theoretical risks and benefits 11 before proceeding with CSI immediately before, during, or immediately after COVID-19 12 vaccination. 13 14 15 16 Highly effective vaccines are now available to the general public for the prevention of 17 severe SARS-CoV-2 infection. [1] [2] However, recent data has demonstrated decreased vaccine 18 efficacy amongst immunocompromised populations such as those with solid organ transplants, 3-4 19 hematologic malignancies, 5-6 and those undergoing chemotherapy. 7 This raises the concern that 20 immunosuppressive effects of corticosteroids (CS) might also result in decreased COVID-19 21 vaccine efficacy, though no study has yet been published on this topic. 22 Corticosteroid injections (CSI) are commonly used in hand surgery, spine surgery, 23 rheumatology, physiatry, and pain medicine, with specific choice of steroid and dose varying 24 depending on indication and provider preference. In the absence of specific data, our colleagues 25 in other specialties are drawing on existing data regarding the impact of CSI on non-COVID 26 vaccine efficacy in order to make recommendations about CSI when given in the peri-27 vaccination period. Hand surgeons may be less cognizant of these recommendations as position 28 statements regarding CSI and COVID vaccination have not been publicly shared from AAOS, 29 ASPS, ASSH, and AAHS. † 30 31 While hand surgeons commonly consider CSI to be a localized dose of medication with a 33 small amount of overall systemic absorption, the effects of this systemic response are 34 measurable. The potential impact of intra-articular and epidural steroid injections on blood 35 glucose in patients with diabetes has been the subject of numerous studies. Small cohort studies 36 tracking blood glucose levels after injection of various steroids (triamcinolone, betamethasone, 37 methylprednisolone) at various sites (tendon sheath, carpal tunnel, intra-articular, epidural) 38 demonstrate wide agreement that there is a definite increase in blood glucose levels following 39 injection and the effects disappear after 2-5 days. 7-14 40 Studies of epidural CSI may also be relevant. Epidural CSI and systemic glucocorticoid 41 levels in the weeks following injection were studied to assess possible systemic effects. 15 In this 42 randomized, double blinded, placebo controlled, multi-center trial, morning serum cortisol levels 43 were measured at baseline and 3 weeks after injection in 400 patients ages 50 or greater with 44 spinal stenosis. Subjects received lidocaine alone (placebo), or lidocaine with betamethasone (6-45 12 mg), dexamethasone (8-10 mg), methylprednisolone (60-120 mg), or triamcinolone (60-120 46 mg). There was an average 14.4% reduction in serum cortisol at week 3 for those receiving CSI 47 compared to baseline, whereas those with lidocaine alone had an 8.2% increase in cortisol. 48 Approximately 20% of patients experienced a 50% or larger reduction in serum cortisol after CSI 49 at 3 weeks, and 3.2% of patients with CSI had near complete cortisol suppression (90% or 50 greater suppression of baseline) at 3 weeks. This study demonstrated that a subset of patients was 51 more sensitive to systemic steroid effect after relatively large doses of epidural steroid injections 52 (twice or more those typically given for hand surgery indications). The authors were unable to 53 predict who would develop hypersensitivity to CSI, but were able to demonstrate that certain 54 steroids caused more systemic effect at 3 weeks than others. Betamethasone and 55 methylprednisolone injections did not differ significantly from lidocaine only (placebo) injection 56 values at 3 weeks compared to baseline, whereas triamcinolone and dexamethasone were 57 significantly more likely to result in cortisol suppression at that time point (41.0% and 41.6%, 58 respectively). 59 Currently no direct data exists to address the efficacy of COVID-19 vaccination in the 61 setting of CSI. The most common vaccination studied with steroids has been influenza 62 vaccination. In a retrospective influenza study at Mayo Clinic, 16 patients treated over 5 years 63 during influenza season who received large joint injections with CSI with or without flu 64 vaccinations were compared to another "control" population of patients who received flu 65 vaccination only. The relative risk of developing influenza was statistically significant at 1.52 66 times higher in those who received large joint CSI, compared to those who did not. However, the 67 J o u r n a l P r e -p r o o f overall number of patients who developed influenza based on clinical diagnosis within their 68 medical record was quite low overall in both groups: 1.08% for the control group (vaccinated but 69 no CSI) and 1.64% (vaccinated + CSI), and 1.70% (CSI without vaccination). It is unknown how 70 many of the unvaccinated group may have been vaccinated outside of the medical system or how 71 many of the non-CSI group may have received CSI elsewhere. Of note, those confirmed with 72 influenza who received a CSI had methylprednisolone (78. If patients receive short-acting steroids, such as dexamethasone and 124 betamethasone, a 2-week waiting period for vaccination may be appropriate. 125 In reference to long-acting steroids, i.e., methylprednisolone or 126 triamcinolone, of 80 mg or greater, it may be appropriate to wait at least 4 weeks 127 prior to the vaccination to avoid any interference. there is no data that a CSI alone will significantly impair the immune response to the SARS-175 CoV-2 vaccine at this time. However, as specialty society guidance is published, it will impact 176 J o u r n a l P r e -p r o o f patient and physician opinions in other specialties. For example, it is now clear that patients with 177 severe immunologic deficiency, such as organ transplantation immunosuppression, hematologic 178 malignancy, and solid tumor chemotherapy do have an impaired response to vaccination. It is 179 possible that specialty societies will further incorporate this newer data into their 180 recommendations regarding CSI and vaccination, though one must be cautious in extrapolating 181 these results as the immunological effects of a single CSI are vastly different than the more 182 profound immunosuppressed states described above. 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