Your questions on steroids

Q) I am 80 years old and have suffered with rheumatoid arthritis for 16 years, for which I take a meloxicam tablet two or three days (and omeprazole to protect my stomach). This controls the arthritis quite well most of the time but after a bad flare up recently my GP suggested I go on steroid injections. I feel reluctant to do this and would be grateful for your comments.

Mr Wells, Crawley - 2012

A) Steroid injections (into muscles, not joints) are one way of controlling flare-ups of arthritis. Despite the relatively large dose of steroid injected, there are probably fewer side-effects taking steroids this way, as opposed to a daily oral dose. However, if you need steroids then your disease isn’t very well controlled. Disease control can be achieved with a number of drugs, not including meloxicam, and these therapies include methotrexate, sulfasalazine and the biologics. It is possible you have had these, or your doctor feels they are too strong for you, and that is why the steroid injections have been suggested.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.

Q) Can I have steroid injections for arthritis in my neck and head? I had them in my shoulder for rotator cuff and they were very effective.

Doreen Higgins - 2015

A) Steroid injections into the neck are used much less often than injections into the shoulder. They're far more complicated than joint injections to the shoulder or knee, so they need to be given by specialists in hospital using x-ray guidance.

These injections are used mostly to relieve pain that radiates into the arms from the neck because of nerve irritation. They're an option when the pain isn’t settling with simple treatments such as painkillers, physiotherapy and exercises.

Some people have injections into the facet joints of the neck if the pain of arthritis in these joints isn't improving with other treatments. Again, these need to be done in hospital, and while they may improve pain in the short term, unfortunately they don't cure the arthritis or the pain in the long term.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) I am 84 and have osteoarthritis of the hip. In 2009 I was diagnosed with polymyalgia rheumatica (PMR) and put on 30 mg of steroids which rapidly sorted the pain of both the hip and the PMR. By 2011 the prednisolone was tapered to 5mg every other day. I insist on continuing with the 5 mg of prednisolone every other day (despite my GP’s opposition) because together with 2 g of paracetamol daily it alleviates the hip pain. Am I right in believing that this continuing dose contributes to pain relief and is unlikely to cause harm? I have a DEXA scan every six months which has now shown osteoporosis. It is patently absurd for an 85-year-old man to risk hip replacement so he can run instead of hobble; opiates are very unpleasant, and NSAIDs produce ulcers.

G.R. K, Herts - 2013

A) It would be a mistake to have a hip replacement if you can satisfactorily control your symptoms by other means. Although hip replacements are highly successful operations, and relieve suffering for thousands of people each year, they are not without risk and should not be undertaken lightly. I don’t see any problem doing exactly what you are doing to control your symptoms. If that is all it takes to keep you going then it is worth any risk. What are the risks? Well, your doctor identifies osteoporosis as a significant risk and it has been shown recently on your bone density scan. But remember, at your age, bone is lost anyway, and I would have been surprised to find that you had a normal bone density. Keeping active, which the drugs allow you to do, will help prevent further bone loss, and you could also take calcium and vitamin D supplements.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) I’m a rheumatoid arthritis sufferer of about 20 years, on prednisolone and methotrexate. I recently had a coronary followed by two procedures for angioplasty and a heart bypass. I believe I suffered a slower recovery because the management of my prednisolone post-operatively could have been handled better. Could you comment?

M. Childs, Kent - 2010

A) It's difficult to comment as you don’t say in what way you think the dosage of prednisolone could have been altered for the better. Some doctors believe that methotrexate should be stopped during operations and such like as it may delay healing, but clinical trials have shown no basis for this. Steroids, including prednisolone, should be increased during times of physical stress and then tapered to their former dose when the stress is over. A heart attack, or coronary, is just one example of such stress, and an operation would be another. Why do you need more steroid during times of physical stress? Normally your body produces more of these naturally occurring hormones during such periods, but if you've been on steroids for some time the body is less able to respond. In these cases, we artificially increase the dose of steroid to do the job the body would normally do.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) I was interested to read in Arthritis Today about the lady from Liverpool who felt ‘cured’ while taking antibiotics. I have had a similar ‘cure’ but with steroids for a gum infection. I was taking prednisolone 5 mg dissolved in 10 ml of water as a mouthwash given to me by my orthodontist. I was amazed to find that after a few weeks of taking prednisolone the pain and stiffness in my knees went and I was able to walk normally, and for once forget all about the two knee replacements I’ve been told I need. Although the prednisolone didn’t cure my gums my GP wouldn’t hear of giving me even a mg of prednisolone to ease my knees. I just don’t understand how well I felt on prednisolone regarding my knees and felt I found ‘my cure’. How can two knee replacements be a better option than a steroid?

Margaret, Devon - 2012

A) Well, you pose an interesting question! Your doctor will be anxious to avoid giving you steroids because of the known long-term side-effects of the drug. These include weight gain, diabetes and osteoporosis. Knee replacements are not without risks. However, on balance, you would be best to avoid the steroid option as my guess is that they would stop working so well after a while (a phenomenon known as tachyphyllaxis) and you would still be faced with the prospect of knee replacements but with the added risk of thinner bones and more weight.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.

Q) I have arthritis in my hip which will require a hip replacement in due course. Would it be possible or advisable to have a steroid injection in the hip while waiting for surgery?

Margery, New Moston, Manchester - 2014

A) Surgeons, on the whole, don’t like you to have a steroid injection into a joint they are likely to operate on in the near (some say up to six months) future. The reason they give is that injections of steroid may introduce bacteria, or lower the ‘resistance’ of the joint to bacteria, so that there is more chance of the new joint becoming infected after the operation. This is a dreaded complication of artificial joint surgery and something that surgeons will avoid at all costs. Don’t forget that if you have rheumatoid arthritis, rather than osteoarthritis, most people will also taking drugs to lower immunity and this may slightly increase the risk of infection. If you are planning to have a steroid injection while waiting for the operation it is best to check with the surgeon beforehand as I have known surgeons cancel the operation on learning that an injection was carried out in the recent past.

This answer was provided by Dr Philip Helliwell in 2014, and was correct at the time of publication.