Recommendations and Guidance for Steroid Injection Therapy and COVID-19 Vaccine Administration from the American Society of Pain and Neuroscience (ASPN)

Abstract

To date, COVID-19 has spread to more than 108 million people globally, with a death toll surpassing 2 1/2 million. With the United States Food and Drug Administration (FDA) approval of two highly effective COVID-19 vaccines from Pfizer-BioNtech and Moderna, we now have a novel approach to contain COVID-19 related morbidity and mortality. Chronic pain care has faced unprecedented challenges for patients and providers in this ever-changing climate. With the approval of COVID-19 vaccines, we now face questions relating to the potential effects of pain treatments utilizing steroids on vaccine efficacy. In this analysis, we address these issues and provide guidance for steroid therapies based on available data and expert recommendations.

Endocrine risk factors for COVID-19: Endogenous and exogenous glucocorticoid excess

“…Studies on the functional vaccine outcomes in patients with chronic high-dose GC therapy point toward a potentially impaired vaccine-based immunity with decreased serologic responsiveness in individuals with exogenous GCs [94][95][96]. However, the decrease of vaccine efficacy in these setting was small, and it has been rather established that patients with chronic GC treatment generate an adequate humoral response to vaccines [97][98][99][100]. The use of intraarticular corticosteroids was previously associated with an increased risk for developing influenza despite vaccination [101].…”

“…Due to the long-lasting systemic effects of intraarticular corticosteroid injections and the time to establish an effective response of the adaptive immune system, it is suggested to conduct an elective corticosteroid injection no less than two weeks prior and one week following mRNA vaccine dose, whenever possible [102,103]. However, on the other hand, there are also studies that do not see any connection between vaccine responsiveness and short-term systemic GC administration [100,104,105]. To the best of our knowledge, there are no available studies on vaccine response in patients with endogenous GC excess.…”

“…Noteworthy, all vaccines approved or currently in latestage development, including vaccines based on mRNA, are considered inactivated vaccines. With regard to live vaccination, there are safety concern with systemic GC doses equivalent to 2 mg/kg or a dose of 20 mg per day of prednisone equivalents for 2 or more weeks [100,110,111]. However, non-live vaccines can be used without restrictions in patients under immunosuppressive therapy [112].…”

COVID-19 Vaccines and Anesthesia

“…Ülkemizde yaygın olarak kullanılan CoronaVac (Sinovac) aşısı ile ilgili bilgiler sınırlı olmakla birlikte, 2. dozdan 14 gün sonra anlamlı bağışıklık oluşturduğu bildirilmiştir (19) . (20) . Kronik yüksek doz steroid kullanımının aşı immün yanıtını bozabileceği fakat bu etkinin zayıf olduğu bildirilmiştir (21,22) .…”

“…Asetaminofen ve naproksenin farmakolojik dozlarda benzer etki gösterdiği bildirilmiştir. Artan NSAİA dozlarıyla orantılı olarak Ig üretiminin azaldığı gösterilmiştir (20) . Yaşlı hastalarda, düşük doz aspirinin H1N1 influenza aşı etkinliği üzerine etkisi olmadığı bildirilmiştir (27) .…”