The systemic immunosuppressive effects of peripheral corticosteroid injections: A narrative review of the evidence in the context of COVID‐19

Abstract

Introduction Injected glucocorticoid's (corticosteroids) are commonly used in musculoskeletal practice. The current global COVID‐19 pandemic has increased attention on the potential for locally injected corticosteroids to exert a systemic immunosuppressive effect and the implications this may have in relation to COVID‐19 infection and vaccination. Aim This narrative review summarises the evidence regarding the potential systemic immunosuppressive effects of peripheral corticosteroid injections in relation to the ongoing COVID‐19 pandemic. Method A narrative review was selected to allow inclusion of evidence related to a diverse range of topics relevant to this subject in order to provide the most comprehensive and clinically relevant guidance for clinicians. Results/discussion Current evidence demonstrates that cytotoxic, phagocytic and antigen presenting cells involved in both the innate and adaptive immune responses are suppressed for 48 h post‐injection and messenger cytokines that are integral to immune function are suppressed for over 96 h post‐injection. This potentially reduces an individual's ability to prevent viral infection, limit early viral replication, and delays activation of adaptive immune mechanisms (T and B lymphocytes) and subsequent viral clearance and elimination. The hypothalamic–pituitary–adrenal (HPA) axis can be suppressed for 2–4 weeks or longer following peripheral corticosteroid injections. The role of the HPA axis in immune function is not fully understood, however this could potentially indicate longer lasting immunosuppression. Conclusions This review found evidence of suppression of immune cell numbers for the first 48 h post‐injection, cytokines for over 96 h post‐injection and HPA axis suppression lasting for 2–4 weeks or longer. There is currently no evidence that these physiological changes translate into a clinically meaningful increased risk of COVID‐19 infection or related morbidity or mortality, but there is also no persuasive evidence that they do not. This review discusses the implications of the current evidence in relation to shared decision making, informed consent, risk management and COVID‐19 vaccination to provide clinicians with a pragmatic guide to help navigate the current uncertainty regarding the potential immunosuppressive effects of peripheral corticosteroid injections.

Steroid injections in musculoskeletal conditions and COVID infection rates: What is the impact on positive rates following the injection?

“…Extensive counselling and written consent process including the discussion of the risks and benefits of the CSI prior to receiving the injection may have led to greater caution being shown by the participants and taking more precautions with regards to social contact and self‐isolation/distancing and carrying out more effective hand hygiene measures in the knowledge that the steroid can reduce the immune response. The findings of this study are consistent with and in keeping with other studies (Aziz et al., 2021 ; Bugeja et al., 2021 ; Chang et al., 2021 ; McKean et al., 2020 ; Morgan & Dattani, 2020 ; Newton et al., 2021 ; Regan et al., 2021 ). The risk identified within those studies demonstrated extremely low infection risk with very few or no positive cases of COVID‐19 infection following CSI.…”

Pathogenesis and treatment of chronic rhinosinusitis from the perspective of sinonasal epithelial dysfunction

“…Corticosteroids have well-known anti-inflammatory effects and generally suppress adaptive responses and enhance innate responses ( 99 ). The medical treatment of CRS mainly involves the application of topical, intranasal, and oral corticosteroids ( 100 ).…”

Incidence and Risk Factors of Systemic Adverse Effects and Complications of Ultrasound- and Fluoroscopy-Guided Glucocorticoid Injections

“…Theoretically, GCIs may lead to short-term systemic immunosuppression, as it decreases the number of immune cells and cytokines for a few days and would therefore increase the risk of developing a bacterial or viral systemic infection, such as the COVID-19 infection. 5 However, this theoretical increased risk of developing a systemic infection did not translate into clinical findings. Two other retrospective studies found similar results and concluded that GCIs did not increase the likelihood of a COVID-19 infection.…”

“…1,3,4 As the COVID-19 pandemic still represents a global concern, there are speculations that GCI could increase the likelihood of developing a COVID-19 infection because of its impact on the immune system. 5 The incidence rate of most of these systemic adverse effects and complications of GCI remains unclear in the medical literature.…”

“…Moreover, possible systemic complications (rare unwanted GCI consequences that can be harmful and require further medical attention) include infection due to relative immunosuppression, abnormal uterine bleeding (AUB), erectile dysfunction, acute coronary syndrome (ACS), decompensated heart failure (HF), avascular necrosis at a distant site (mostly with oral glucocorticoids), osteopenia, and adrenal insufficiency 1,3,4 . As the COVID-19 pandemic still represents a global concern, there are speculations that GCI could increase the likelihood of developing a COVID-19 infection because of its impact on the immune system 5 . The incidence rate of most of these systemic adverse effects and complications of GCI remains unclear in the medical literature.…”