A Retrospective Study Evaluating Risks Associated with Musculoskeletal Corticosteroid Injections in Patients with Diabetes

BACKGROUND: Musculoskeletal (MSK) corticosteroid injections (CSIs) are commonly used to treat patients with osteoarthritis (OA). Despite local administration, intraarticular CSI have been shown to be absorbed into the circulation and cause systemic effects lasting days to weeks. One concerning side effect, especially among diabetic patients, is transient hyperglycemia. OBJECTIVE AND METHODS: This study aimed to determine the percentage of patients undergoing MSK CSI with a known diagnosis of diabetes (DM) and determine the rate of adverse diabetes-related healthcare events. We performed a retrospective chart review of 7,886 patient encounters where patients received 1 or more MSK CSIs between January 1, 2016 and April 30, 2019 from 17 outpatient clinics associated with a single, large community hospital in Dallas, TX. Retrospectively we identified adverse diabetes-related healthcare events requiring an acute intervention within 1 week of the injection. RESULTS: We found 2,428 of 7,886 (30.8%) CSIs were administered to patients with DM. By injection site, 461 of 1,835 (25.2%) axial injections and 1,967 of 6,051 (32.5%) appendicular injections were administered to patients with DM. The patients receiving axial injections compared to appendicular injections were younger (58.5 +/-9.7 and 62.5 +/-10.0, respectively; p = 0.000) and had a lower baseline hemoglobin A1c level (6.9 +/-1.1 and 7.1 +/-1.4, respectively; p = 0.003). 29 of 2,428 DM patients experienced hyperglycemia and required interventions, which included 1 hospital admission, 3 ER visits, and 25 office visits and/or phone calls. Acute interventions included change in oral medication and/or insulin dosage, IV insulin, IV fluids and/or hospital admission. The overall adverse event rate was 1.19%, with rates of 0.65% and 1.32% for injections following axial and appendicular sites, respectively. Currently there is no standard of care regarding MSK CSI use among diabetic patients and there are no clinical guidelines regarding the safety of or risks associated with steroid injections in diabetic patients. CONCLUSIONS: This is the first report to assess the clinical consequence of increased glucose levels following MSK CSI showing 1.19% of injections requiring acute diabetic intervention in the week following injection. Adverse event rates were higher following appendicular versus axial injections, though baseline differences and low event rates limit between group comparisons. Further research is needed.