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Xie Z, Wang L, Chen J, Zheng Z, Srinual S, Guo A, Sun R, Hu M. Reduction of systemic exposure and side effects by intra-articular injection of anti-inflammatory agents for osteoarthritis: what is the safer strategy? J Drug Target 2023; 31:596-611. [PMID: 37249274 DOI: 10.1080/1061186x.2023.2220083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/03/2023] [Accepted: 04/05/2023] [Indexed: 05/31/2023]
Abstract
Osteoarthritis (OA) is a chronic degenerative joint disease associated with pain, inflammation, and cartilage degradation. However, no current treatment can effectively halt the progression of the disease. Therefore, the use of NSAIDs and intra-articular corticosteroids is usually recommended as the primary treatment for OA-associated pain and inflammation. However, there is accumulating evidence that the long-term use of oral NSAIDs and intra-articular corticosteroids can lead to a myriad of negative side effects. Although numerous efforts have been made to develop intra-articular formulations for NSAIDs, the systemic exposure of intra-articular injection of NSAIDs and its potential side effects have not been explicitly investigated. To ascertain the evident and potential side effects of intra-articular injection of anti-inflammatory agents, we have summarised in this review the systemic exposure, local side effects, and systemic side effects of intra-articular injections of anti-inflammatory agents, including NSAIDs and corticosteroids. For developing a safer treatment to fulfil the unmet long-term use needs of patients, a new therapy, which combines the locally active drug and a sustained-release formulation, has been proposed in this review.
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Affiliation(s)
- Zuoxu Xie
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
- Drug Metabolism and Pharmacokinetics, Biogen, Cambridge, MA, USA
| | - Lu Wang
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Jie Chen
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Zicong Zheng
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Songpol Srinual
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Annie Guo
- Drug Metabolism and Pharmacokinetics, Biogen, Cambridge, MA, USA
| | - Rongjin Sun
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Ming Hu
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX, USA
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Manzo C, Serra-Mestres J, Castagna A, Isetta M. Behavioral, Psychiatric, and Cognitive Adverse Events in Older Persons Treated with Glucocorticoids. MEDICINES (BASEL, SWITZERLAND) 2018; 5:E82. [PMID: 30071590 PMCID: PMC6163472 DOI: 10.3390/medicines5030082] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 01/22/2023]
Abstract
Background: Since the introduction of glucocorticoids (GCs) in the physician's pharmacological arsenal, it has been known that they are a cause of behavioral or psychiatric adverse events (BPAE), as well as of cognitive problems. To the best of our knowledge, the relationship between these adverse events and GCs in older persons has never been evaluated, except through case-reports or series with few cases. In this paper, a review of the literature regarding BPAEs and cognitive disorders in older people treated with CSs is undertaken. Methods: A comprehensive literature search for BPAEs was carried out on the three main bibliographic databases: EMBASE, MEDLINE and PsycINFO (NICE HDAS interface). Emtree terms were: Steroid, steroid therapy, mental disease, mania, delirium, agitation, depression, behavior change, dementia, major cognitive impairment, elderly. The search was restricted to all clinical studies and case reports with focus on the aged (65+ years) published in any language since 1998. Results: Data on the prevalence of the various BPAEs in older patients treated with GCs were very scarse, consisting mainly of case reports and of series with small numbers of patients. It was hence not possible to perform any statistical evaluation of the data (including meta-analysis). Amongst BPAEs, he possibility that delirium can be induced by GCs has been recently been questioned. Co-morbidities and polypharmacy were additional risk factors for BPAEs in older persons. Conclusions: Data on BPAEs in older persons treated with GCs, have several unmet needs that need to be further evaluated with appropriately designed studies.
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Affiliation(s)
- Ciro Manzo
- Rheumatologic Outpatient Clinic and Geronthorheumatologic Service, 80065 Sant'Agnello, Italy.
- Center for Cognitive Diseases and Dementias, 80038-ASL Napoli 3 Sud Pomigliano d'Arco, Italy.
| | - Jordi Serra-Mestres
- Department of Old Age Psychiatry, Central and North West London NHS Foundation Trust, London UB8 3NN, UK.
| | - Alberto Castagna
- Center for cognitive diseases and dementias, Catanzaro lido, ASP Catanzaro, 88100 Catanzaro, Italy.
| | - Marco Isetta
- Library and Knowledge services, Central and North West London NHS Foundation Trust, London UB8 3NN, UK.
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Habib G, Khatib M, Sakas F, Artul S, Jabaly-Habib H. Pre-injection of hyaluronic acid does not affect the systemic effects of intra-articular depot betamethasone injection at the knee joint. Clin Rheumatol 2016; 36:217-221. [PMID: 27423207 DOI: 10.1007/s10067-016-3352-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/02/2016] [Accepted: 07/07/2016] [Indexed: 11/25/2022]
Abstract
Intra-articular injection (IAI) of both hyaluronic acid (HA) and depot-steroid preparations had the advantage of quick and prolonged favorable effects on pain relief among patients with symptomatic osteoarthritis of the knee (OAK). The effect of IAI of HA on the systemic effects of the intra-articular steroids had not been investigated. Non-selected patients attending the rheumatology clinic with symptomatic OAK who failed NSAIDS and physical therapy were offered an IAI of HA at the knee joint followed 20 min later by an IAI of 1 ml of Celestone Chronodose at the same joint (group 1). Morning serum levels of cortisol were obtained just prior to the IAI and 1, 2 and 8 days later. Demographic, clinical, and laboratory parameters were obtained also from all the patients. Age- and sex-matched group of patients from the same clinic were recruited as a control group (group 2). Mean baseline serum cortisol levels in group 1 was 381 ± 154 mmol/l vs. 376 ± 119 in group 2 (p = 0.954). Morning serum cortisol levels at day 1 and day 2 were 24 ± 6 and 22 ± 6 mmol/l, respectively, in group 1 patients vs. 27 ± 5.8 (p = 0.214) and 25 ± 5.6 mmol/l (p = 0.200), respectively, in group 2. These levels were significantly lower than baseline levels in each group. Morning serum cortisol levels at day 8 in group 1 and group 2 were 349 ± 128 and 314 ± 99 mmol/l, respectively (p = 0.419). Pre-injection of HA at the knee joint did not affect the systemic effect on the hypothalamic-pituitary-adrenal axis of IAI of Celestone Chronodose.
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Affiliation(s)
- George Habib
- Rheumatology Unit, Laniado Medical Center, Netanya, 42150, Israel. .,Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel. .,Rheumatology Clinic, Nazareth Hospital, Nazareth, Israel.
| | - Muhamad Khatib
- Department of Medicine, Poriya Medical Center, Poriya, Israel
| | - Fahed Sakas
- Department of Medicine, Rambam Medical Center, Haifa, Israel
| | - Suheil Artul
- Gallile Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.,Department of Radiology, Nazareth Hospital, Nazareth, Israel
| | - Haneen Jabaly-Habib
- Gallile Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.,Ophthalmology Division, Poriya Medical Center, Poriya, Israel
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Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections. Expert Opin Drug Saf 2016; 15:1031-9. [DOI: 10.1080/14740338.2016.1184246] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Byron Schneider
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Patricia Zheng
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Ryan Mattie
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - David J. Kennedy
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
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Agrawal K, Ebel JG, Bischoff K. A rapid screen for four corticosteroids in equine synovial fluid. J Anal Toxicol 2014; 38:272-9. [PMID: 24713534 DOI: 10.1093/jat/bku030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Most antidoping method development in the equine industry has been for plasma and urine, though there has been recent interest in the analysis of synovial fluid for evidence of doping by intra-articular corticosteroid injection. Published methods for corticosteroid analysis in synovial fluid are primarily singleplex methods, do not screen for all corticosteroids of interest and are not adequately sensitive. The purpose of this study is to develop a rapid and sensitive liquid chromatography-tandem mass spectrometry (LC-MS-MS) screening method for the detection of four of the most common intra-articularly administered corticosteroids--betamethasone, methylprednisolone, methylprednisolone acetate and triamcinolone acetonide. Sample preparation consisted of protein precipitation followed by a basified liquid-liquid extraction. LC-MS-MS experiments consisted of a six-min isocratic separation using a Phenomenex Polar-RP stationary phase and a mobile phase consisting of 35% acetonitrile, 5 mM ammonium acetate and 0.1% formic acid in nanopure water. The detection system used was a triple quadrupole mass analyzer with thermospray ionization, and compounds were identified using selective reaction monitoring. The method was validated to the ISO/IEC 17025 standard, and real synovial fluid samples were analyzed to demonstrate the application of the method in an antidoping context. The method was highly selective for the four corticosteroids with limits of detection of 1-3 ng/mL. The extraction efficiency was 50-101%, and the matrix effects were 14-31%. These results indicate that the method is a rapid and sensitive screen for the four corticosteroids in equine synovial fluid, fit for purpose for equine antidoping assays.
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Affiliation(s)
- Karan Agrawal
- 1Department of Forensic and Analytical Science, King's College London, London, UK
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Edwards SHR. Intra-articular drug delivery: the challenge to extend drug residence time within the joint. Vet J 2010; 190:15-21. [PMID: 20947396 DOI: 10.1016/j.tvjl.2010.09.019] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 02/02/2023]
Abstract
The rationale behind developing sustained release microsphere formulations of non-steroidal anti-inflammatory drugs (NSAIDs) administered via the intra-articular (IA) route is to minimise the systemic bioavailability and attendant side-effects associated with oral drug administration. Overall dose is reduced whilst therapeutic benefit within the joint is maintained. The potential benefits of IA therapy for osteoarthritis (OA) are not achieved using currently available medications and delivery vehicles due to the rapid clearance of therapeutic substances from the synovial space. There is a need for sustained release delivery systems if the potential of IA drug administration is to be realised. Rationally designed microspheres taken up by synovial macrophages offer a strategy to sustain drug delivery within the joint, and to deliver NSAIDs directly to pivotal inflammatory cells. The efficacy of microsphere candidates may be evaluated in large animal models of OA. The principles of IA microsphere drug delivery may also be applicable to other classes of drugs.
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Affiliation(s)
- Scott H R Edwards
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia.
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7
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Habib GS. Systemic effects of intra-articular corticosteroids. Clin Rheumatol 2009; 28:749-56. [PMID: 19252817 DOI: 10.1007/s10067-009-1135-x] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 02/04/2009] [Accepted: 02/09/2009] [Indexed: 11/29/2022]
Abstract
The objective of this study was to review all the published articles in the English literature about the systemic effects of intra-articular corticosteroid injection (IACI) in humans. Reports were searched through Pubmed using the terms intraarticular or intra-articular and steroids, corticosteroids, or glucocorticosteroids up and including the year 2007. Reports were also located through references of articles. Only objective findings outside the injected joint were included. The overwhelming majority of the studies was done at the knee joint and in rheumatoid arthritis/juvenile idiopathic arthritis patients. Many of the studies were done on the hypothalamic-pituitary-adrenal axis. Serum cortisol decreased within hours with a nadir after usually 24-48 h following the IACI. Recovery to baseline takes 1-4 weeks and sometimes longer depending on the type and dose of IACI and on the number of injected joints. Serum cortisol levels were blunted following adrenocorticotropic hormone stimulation in a small proportion of patients following methylprednisolone acetate injection and more common following other preparations. IACI resulted in a transient increase in blood glucose levels over few days in controlled diabetic patients with knee osteoarthritis. Peak levels are around 300 mg%. IACIs are associated with reduction in inflammatory markers like C-reactive protein and erythrocyte sedimentation rate that start few days following the IACI and could last for months. The effect on inflammatory cytokines is immediate with significant decrease within hours. IACI may induce remission also in patients with oligo-/polyarthritis and/or in patients with extra-articular manifestations. Other metabolic, hematologic, vascular, allergic, visual, psychologic, and other effects were also reported.
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Affiliation(s)
- George S Habib
- Department of Medicine, Carmel Medical Center, Haifa, 34362, Israel.
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8
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Nicholas JJ. Articular and Soft-Tissue Injections. Phys Med Rehabil Clin N Am 1996. [DOI: 10.1016/s1047-9651(18)30386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Green KL, Foong WC. Treatment of antigen-induced arthritis in rabbits by the intra-articular injection of methylprednisolone, 90Y or chlorambucil. J Pharm Pharmacol 1993; 45:815-20. [PMID: 7903371 DOI: 10.1111/j.2042-7158.1993.tb05692.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Rabbits with a bilateral antigen-induced arthritis were injected intra-articularly (i.a.) in one joint with methylprednisolone (1 mg), 90Y (18.5 MBq) or chlorambucil (1 mg) as a single dose. The severity of arthritis was determined by measuring joint swelling and skin surface temperature, macroscopic and histological changes in the joint being assessed 8 weeks after induction of arthritis when the rabbits were killed. Methylprednisolone injected at the time of antigen challenge or 3 weeks later caused a reduction in joint swelling and temperature (P < 0.05) for 1 to 6 weeks after injection. 90Y had an initial proinflammatory effect lasting several days, but later caused a modest reduction in joint swelling for up to 4 weeks (P < 0.05). Eight weeks after induction of arthritis, neither methylprednisolone nor 90Y-treated joints showed any significant reduction in erosion or histopathology compared with control arthritic joints. Chlorambucil injected 1 week after antigen challenge caused a rapid reduction in joint swelling which was maintained for the duration of the study. Joint surface temperature was reduced to a lesser extent. Eight weeks after induction of arthritis, chlorambucil-treated joints showed a decrease (P < 0.05) in all of the parameters of disease pathology assessed. Treatment with chlorambucil intra-articularly was clearly more effective than with methylprednisolone or 90Y at the doses employed and deserves further study as a potential treatment for chronic synovitis.
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Affiliation(s)
- K L Green
- Drug Delivery Research Group, School of Pharmacy and Biomedical Sciences, University of Portsmouth, UK
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10
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Smith MD, Ahern MJ, Roberts-Thomson PJ. Pulse methylprednisolone therapy in rheumatoid arthritis: unproved therapy, unjustified therapy, or effective adjunctive treatment? Ann Rheum Dis 1990; 49:265-7. [PMID: 2187419 PMCID: PMC1004053 DOI: 10.1136/ard.49.4.265] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- M D Smith
- Department of Clinical Immunology, Flinders Medical Centre, Bedford Park, South Australia
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Reeves PT, Hanrahan P, Edelman J, Ilett KF. Effect of intra-articular glucocorticoids on the disposition of sulphadimidine in chronic osteoarthritis patients. Br J Clin Pharmacol 1988; 26:563-8. [PMID: 3207561 PMCID: PMC1386633 DOI: 10.1111/j.1365-2125.1988.tb05296.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
1. The disposition of sulphadimidine (15 mg kg-1 orally) was investigated in six chronic osteoarthritis patients (four slow and two fast acetylators) prior to and 4 days following intra-articular administration of glucocorticoids. 2. The mean (+/- s.e. mean) renal clearance of sulphadimidine was increased from 0.03 +/- 0.01 to 0.07 +/- 0.02 ml min-1 kg-1 (P = 0.01) following the administration of intra-articular steroid. 3. Mean metabolic clearance and volume of distribution data were similar on the two study days. However, two of the slow acetylators showed marked increases (63% and 193%) in metabolic clearance following steroid treatment.
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Affiliation(s)
- P T Reeves
- Department of Pharmacology, University of Western Australia, Nedlands
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Affiliation(s)
- David Barraclough
- Suite 17, Private Consulting RoomsThe Royal Melbourne HospitalGrattan StreetParkville VIC3052
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13
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Edelman J, Potter JM, Hackett LP. The effect of intra-articular steroids on plasma salicylate concentrations. Br J Clin Pharmacol 1986; 21:301-7. [PMID: 3485989 PMCID: PMC1400861 DOI: 10.1111/j.1365-2125.1986.tb05194.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Plasma salicylate concentrations and salicylate clearances were evaluated in 10 patients before and then 3 days after the intra-articular administration of glucocorticoid steroids. All patients were on chronic salicylate treatment, the dosage varying from 1.3-4.6 g day-1 of enteric-coated aspirin. The mean steady state plasma concentration (+/- s.e. mean) of salicylate decreased significantly after intra-articular steroid (90.9 +/- 14.8 mg l-1-64.7 +/- 8.9, P less than 0.05), whilst the mean clearance increased significantly (87.3 +/- 20.6 ml min-1-120.6 +/- 28.3, P less than 0.05). In these paired studies, the intra-articular administration of steroids lead to a significant decrease in plasma salicylate levels in patients taking enteric-coated aspirin.
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