Drug formulary listing decision – Corticosteroid injections in musculoskeletal conditions

Corticosteroid injections in musculoskeletal conditions

Indications/Clinical uses

Treatment of acute and chronic musculoskeletal conditions including neck and upper extremity disorders (carpal tunnel syndrome, neck and upper extremity pain), shoulder disorders (adhesive capsulitis, partial rotator cuff tears, shoulder impingement syndrome, shoulder pain), tenosynovitis (trigger digits, De Quervain’s syndrome), tendinopathy (lateral epicondylitis, Achilles tendon, rotator cuff), exacerbation of osteoarthritis (knee, hand/thumb, hip), bursitis (olecranon, trochanteric), radiculopathy, low-back pain

Formulary status

The Drug Advisory Committee (DAC) recommended corticosteroid injections used in musculoskeletal conditions be listed on WSIB formularies: Initial (25WS), Musculoskeletal (02WS), CNS/PNS (03WS), Chronic Pain Disability (23WS), and Serious Injury (27WS).

WSIB accepts the DAC recommendation.

Recommendation highlights

  • Injectable corticosteroids comprise of chemical entities betamethasone, dexamethasone, hydrocortisone, methylprednisolone and triamcinolone. All have anti-inflammatory effects in the treatment of corticosteroid-responsive musculoskeletal disorders. Non-systemic, locally-administered corticosteroid injections are usually given by a health care professional such as a physician or a nurse practitioner into a joint, or its surrounding structures (e.g., bursa).
  • There is extensive evidence on the efficacy and safety of corticosteroid injections in the treatment of musculoskeletal conditions relevant to WSIB, as per the commissioned literature review encompassing 2011-2021. Over 70 systematic reviews and meta-analyses, evaluating pain and improvement of functional disability in over 80,000 adult patients were included. Injectable corticosteroids demonstrated modest reduction in pain and improvement in function when compared to active or placebo interventions in the treatment of carpal tunnel syndrome, adhesive capsulitis, shoulder disorders, tendinopathies, trigger digits, De Quervan’s syndrome, lateral epicondylitis, and knee osteoarthritis. The evidence of their therapeutic value is contradictory in other musculoskeletal conditions; treatment should be based on consensus expert opinion and clinical features, as well as continued on demonstrated effectiveness after first injection.
  • The evidence supports short-term (usually four to 12 weeks) treatment and it should continue for no more than four injections.
  • The use of corticosteroid injections locally is generally considered safe and is associated with fewer adverse events than oral corticosteroids. Common adverse events include post-injection flare, facial flushing and skin/fat atrophy. Joint sepsis, tendon ruptures and articular cartilage damage are serious complications that can partially be avoided by improved injection technique and avoiding large doses. Rare neurologic injuries, including stroke and spinal cord damage, may occur with epidural injections.
  • There is lack of clear guidelines on the use of injectable corticosteroids in the management of musculoskeletal conditions. Despite numerous controversies, these preparations have been used for a long time in practice and are usually administered together with local anaesthetics and supplemented with oral anti-inflammatories and non-pharmacological interventions (physiotherapy or exercise). Consensus in the guidelines is that the effect of corticosteroids in the long term (≥ three months) is unclear and may be associated with adverse effects.
  • Only four economic evaluations of corticosteroid injections in musculoskeletal conditions were directly relevant to the WSIB and considered of sufficient quality to be included in the literature review. The results were varied, as were the study methodologies, modelling, conditions and assumptions. In addition, none of the analyses were completed in Canada using relevant costing, making it difficult to reach any conclusion about overall cost-effectiveness compared to NSAIDs, acetaminophen, non-pharmacological treatment alone or in combination.
  • All Canadian provinces list at least two injectable corticosteroids for use in musculoskeletal conditions. Other Canadian Worker’s Compensation Boards allow funding on case-by-case basis.
  • Therefore, the DAC concluded there is sufficient evidence and widespread safe use to recommend betamethasone, dexamethasone, hydrocortisone, methylprednisolone and triamcinolone injections for listing on WSIB formularies to improve choice of treatment in acute and chronic musculoskeletal conditions.

Products available in Canada:

  • Dexamethasone sodium phosphate 4mg/mL, 10 mg/mL (Omega Laboratories and other generics)
  • Betamethasone sodium phosphate and betamethasone acetate 6mg/ml (Celestone Soluspan® and generics)
  • Hydrocortisone sodium succinate 100 mg-1g (Solu-Cortef® and generics)
  • Methylprednisolone acetate 20 mg/mL-80 mg/mL (Depo-Medrol® and generics)
  • Methylprednisolone sodium succinate 40 mg-1g (Solu-Medrol® and generics)
  • Triamcinolone acetonide 10mg – 40 mg (Kenalog® and generics)
  • Triamcinolone hexacetonide 20mg/mL (Trispan®, Aristospan®)