| #ffffff;" /> | | | | a crystal induced flare, the treatment would be aimed |
| Rheumatoid arthritis (RA) is a chronic, inflammatory, | | | | at this problem and the rheumatologist would be less |
| often progressive condition that is driven by an | | | | inclined to push systemic therapies for the RA. |
| autoimmune process. | | | | Obviously, the tender swollen joints could also be due |
| The early diagnosis of this disease along with | | | | purely to the RA. This would then indicate that perhaps |
| aggressive medical intervention can often lead to | | | | a different direction in the RA therapy may be needed. |
| remission in many cases. | | | | The second major purpose is therapeutic. Injection of |
| In addition to non-steroidal anti-inflammatory drugs | | | | glucorticoid after drawing off the fluid will help suppress |
| (NSAIDS), low doses of glucocorticoids such as | | | | inflammation and make the patient more comfortable. |
| prednisone, methotrexate, and biologic interventions like | | | | Some key points need to be considered: |
| etanercept (Enbrel), adalimumab (Humira), and infliximab | | | | The procedure is a sterile procedure so certain |
| (Remicade). There are also second generation biologic | | | | precautions to maintain sterility should be followed. |
| drugs. These include abatacept (Orencia) and rituximab | | | | The area to undergo “needling” should |
| (Rituxan). | | | | be anesthetized first. Some people use ethyl chloride |
| Unfortunately, some patients will have their disease | | | | spray. At our center, we numb the area with lidocaine |
| managed except for one, two, or perhaps three | | | | before entering the joint. |
| stubborn joints that remain inflamed. | | | | The initial entrance into the joint, after the area has |
| For these patients, an injection of glucocorticoid – | | | | been sterilized and anesthetized, should be done with a |
| better known as “the cortisone shot” | | | | needle attached to an empty syringe so that if fluid is |
| may be helpful for controlling this localized disease. | | | | present, it can be drawn off. |
| Virtually any joint in the body can be injected with | | | | The person doing the procedure should be extremely |
| glucocorticoid. In addition, other areas such as bursae, | | | | experienced. An inexperienced physician can not only |
| tendon sheaths can also be injected with | | | | make the procedure more painful than it should be but |
| glucocorticoid. However, let’s discuss some | | | | they may not perform the procedure correctly. A |
| important issues having to do with swollen joints first. | | | | poorly done procedure may not get the fluid needed |
| When a patient with rheumatoid arthritis- or any | | | | for diagnosis and the injection of glucocorticoid may |
| arthritis for that matter- presents with a swollen, | | | | not be given into the joint where it is needed. A poorly |
| tender, painful joint, it is imperative that an | | | | done procedure can be worse than no procedure. |
| arthrocentesis be performed. This procedure involves | | | | Ultrasound guidance needs to be employed. If the |
| the insertion of a needle into a joint. An arthrocentesis | | | | needle tip is not in the right place, the glucorticoid will |
| serves two purposes. | | | | not be injected into the right area and the patient |
| The first is diagnostic. Regardless of the diagnosis a | | | | won’t have a good outcome. |
| patient has, one cannot assume that the painful | | | | If there is fluid drawn off the joint, that syringe is |
| swollen joint is due to that disease only. | | | | removed with needle in place and the syringe |
| If there is fluid inside the joint, the retrieval and analysis | | | | containing the glucocorticoid is then attached to the |
| of the fluid may show that another problem exists. For | | | | needle and the glucocorticoid is administered. That |
| instance, a patient with a diagnosis of RA with a red | | | | way a patient only needs to get one needle, not two. |
| tender swollen joint may have a septic arthritis- an | | | | The same joint should not be injected more than three |
| infected joint. The only way to make this diagnosis is | | | | times per year. |
| to get the fluid, examine it, and culture it. The treatment | | | | As for areas, other than joints, the same precautions |
| would involve antibiotic therapy and possible more | | | | should apply. In addition, prior to injecting into soft tissue |
| drainage of the infected joint. Why is this important? | | | | (muscle, tendon, bursa), the doctor should always draw |
| Because septic arthritis is a potentially crippling and life | | | | back on the syringe first to make sure the needle is |
| threatening problem, particularly in patients with | | | | not inside a blood vessel. If the glucorticoid solution is |
| rheumatoid arthritis who may be on | | | | injected directly into a vein, severe problems, including |
| immunosuppressive therapies.. | | | | death can occur. |
| Another example is a crystal-induced form of arthritis. | | | | Cortisone shots should never be given through an area |
| Gout and pseudogout can cause painful swollen | | | | of skin that might be infected. Patients with severe |
| inflamed joints in patients with rheumatoid arthritis. | | | | diabetes may notice a spike in their blood sugar for |
| Examination of the fluid obtained from the joint will | | | | two to three days after a cortisone shot. |
| show crystals of either monosodium urate (gout) or | | | | Cortisone shots can cause a “flare” in |
| calcium pyrophosphate (pseudogout). If the diagnosis is | | | | pain the night after the shot. |