Corticosteroid injections not found to be associated with fracture risk in elderly cohort

1. In a cohort of older adults, the use of corticosteroid injections (CSIs) was not associated with increased fracture risk, regardless of osteoporosis status.

2. The cumulative dose of CSI used over four years was also not a predictor of fracture risk.

Evidence Rating Level: 2 (Good)

Corticosteroid injections (CSI) are commonly used in the management of musculoskeletal (MSK) pain, particularly in older adults. While they are formulated to prolong their presence locally at the injection site, there is some systemic absorption of CSIs. As a result, there is the potential for placing patients at risk for adverse effects of corticosteroids over time, but the extent to which this takes place is not well-studied. One such adverse effect of oral corticosteroids is osteoporosis, which disproportionately impacts older adults and women over the age of 50. The current cohort study sought to elucidate the potential association between cumulative CSI dosing in primary care settings and fracture risk over a four-year span. Patients could have received methylprednisolone, triamcinolone, betamethasone, or dexamethasone injections), and encounter codes for vertebral, wrist, and hip fractures were classified as osteoporotic fractures. Among the 7197 study participants (mean [SD] age, 64.4 [14.6] years; 61.6% women; 92.6% White), 33,684 total CSIs were given mostly in large joints, and the mean (SD) cumulative CSI dose was 141.8 (159.0 [range, 2.7-2140.3]) mg of triamcinolone equivalents. Over the course of the study, 346 patients (4.8%) sustained new fractures, 43.1% of which were in classically osteoporotic regions. On average, a fracture occurred 11 months after the first CSI injection. A further subgroup analysis of high-risk (n = 1845) versus non-high-risk (n = 4741) fracture patients found that 64% of fractures sustained over the course of the study belonged to high-risk patients, and 45% of these fractures were classic osteoporotic fractures. This is in contrast to the non-high-risk group, in which only 22.9% were classic osteoporotic fractures. Also importantly, there was no significant difference in fracture rate between cumulative CSI dose quartiles (5.5% [quartile 1] vs 3.6% [quartile 4]; χ2 P = .87), and both the non-high-risk and osteoporosis subgroups were not found to have associated risk of fracture based on cumulative CSI dose. Only previous fractures, age, and comorbidity were factors associated with fracture risk. These results are the first to comprehensively account for cumulative CSI dosages, and findings indicate that clinicians should not hesitate to prescribe CSIs based on fracture risk, regardless of risk for osteoporosis. The retrospective nature of this study, as well as the homogeneity in race/ethnicity of participants, limit the generalizability of results. Future studies should follow a more diverse cohort of patients over more sustained periods to assess for overall lifetime fracture risk associated with CSIs. 

Click to read the study in JAMA Network Open

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