The Most Common and Worst Way to Treat Arthritis

STORY AT-A-GLANCE

• Steroids can be administered either orally, topically through a cream or ointment, or by injection. Steroids work by inhibiting the production of inflammatory chemicals, thereby reducing symptoms associated with inflammation

• Three of the most common side effects, even from short term use, are osteoporosis (reduced bone density), cataracts and an increased risk of diabetes. However, more serious effects such as life-threatening sepsis have also been reported

• In one 2019 study, 8% of patients with osteoarthritis of the hip or knees who received one to three steroid injections ended up worse. Adverse effects were observed in 10% of those with OA in the hip and in 4% of those with OA in the knees

• In another study, intra-articular corticosteroid injections more than doubled the cartilage volume loss compared to placebo (−0.21 millimeters versus −0.10 mm), while having no impact on knee pain at their two-year follow-up

• When using steroids for an extended period of time, abruptly stopping the drug can trigger adverse and potentially even lethal effects, depending on how long you've been taking the medication

Analysis by 

Dr. Joseph Mercola

If you have arthritis, chances are you've been offered steroid injections. Unfortunately, mounting research suggests this treatment may actually do far more harm than good — even in the short term.

The first recorded use of steroids can be traced to 1930, when an extract of animal adrenocortical tissue was used to counteract human adrenal failure.1 After more than a decade of testing and research, the first patient with rheumatoid arthritis was treated with steroids.

The results were impressive, and it wasn't long before the drug was prescribed to other patients with arthritis. In 1950, the first oral and intra-articular (joint) formulations were used. Today, steroids can be administered either topically through a cream or ointment, orally or by injection.2

While delivery systems may differ, steroids work by inhibiting the production of inflammatory chemicals, thereby reducing symptoms associated with inflammation, be it systemic or in a precise area such as a joint.

By the 1960s, many toxic side effects and withdrawal symptoms were becoming well-known, and withdrawal protocols had already been formulated.3 To this day, scientists continue to discover harmful effects.

Three of the most common side effects, even from short term use, are osteoporosis (reduced bone density), cataracts and an increased risk of diabetes. However, more serious effects such as life-threatening sepsis (blood poisoning) have also been reported.

Single Steroid Injection Results in Massive Bone Loss

In an October 2019 article4 in The Atlantic, Dr. James Hamblin recounts the disturbing case of a young woman who, after giving birth, complained of pain in her hip. A steroid injection was administered to help with the pain after an X-ray revealed a small amount of fluid in the joint, which can be a sign of inflammation.

Six months later, the woman, now unable to walk, came back to the hospital. Imaging revealed the entire head of her femur was now gone, necessitating a total hip replacement.

While her doctor, Dr. Ali Guerrmazi at the Boston Medical Center, didn't know exactly how it happened, he suspected the bone loss might be related to the steroid injection. As noted by Hamblin:5

Steroid Shots Can Make Joints Worse

Guermazi and colleagues recently published the results of a study6,7,8 in which the outcomes of 459 patients with osteoarthritis (OA) of the hip or knee who were treated with steroids were evaluated. Patients received between one and three intra-articular corticosteroid (IACS) injections (median 1.4 injections) for their OA.

In 8% of these cases, the injection ended up causing complications that made the joint worse.9 Hips appear to be far more prone to damage from the injections than knees, as adverse effects were observed in 10% of those with OA in the hip compared to 4% of those with OA in the knees.10 According to the authors:11

Of these, accelerated OA progression was the most common, accounting for 6% of adverse effects; 0.9% experienced subchondral insufficiency fracture, 0.7% experienced osteonecrosis and 0.7% had rapid joint destruction and bone loss.

They also cite other research12 showing intra-articular corticosteroid injections more than doubled the cartilage volume loss compared to placebo (−0.21 millimeters versus −0.10 mm), while having no impact on knee pain at two-year follow-up.

Evidence to Support Steroid Use Is Lacking

A 2015 meta-analysis13 that looked at 27 trials for arthritis of the knee also concluded that the quality of the evidence in support of steroids was low and, overall, inconclusive. According to the authors, "A single trial included in this review described adequate measures to minimize biases and did not find any benefit of intra-articular corticosteroids."

What's more, the evidence suggests the effects of steroids decrease over time, and this particular analysis found "no evidence that an effect remains six months after a corticosteroid injection." As Guermazi told Hamblin:14

Hamblin continues:15

The fact of the matter is that steroid injections have been suspected of triggering bone loss for quite some time now. In 2006, animal research16 revealed a strong link between steroid use and osteoporosis.

The conclusion of the study revealed that although the steroid cortisone appears to inhibit the ability of osteoclasts to dismantle old bones in genetically normal mice, the inability of the skeletal structure to renew itself may cause bones to weaken dramatically. Senior author Dr. Steven L. Teitelbaum, Messing professor of pathology and immunology commented:17

Knee Steroid Shots Are No More Effective Than Placebo

Similarly, a 2017 study18 published in JAMA presented convincing evidence that use of corticosteroid injections for osteoarthritis of the knee causes a gradual loss of knee cartilage over time and appears to be no more effective than placebo in terms of relieving knee pain.

In this study, a group of 140 men and women over the age of 45 who suffered from painful knee OA were randomly assigned injections of either a corticosteroid or a saline placebo. Those receiving a corticosteroid were injected with 40 milligrams (mg) of triamcinolone acetonide.

The intra-articular injections were administered every three months for two years. The effects of the shots were tracked via pain questionnaires and physical ability tests, as well as annual bone and joint magnetic resonance imaging. Neither the study participants nor the staff administering the shots knew which patients were receiving placebos.

At the conclusion of the study, there was no noticeable difference between the two groups in terms of joint pain and stiffness. Both groups performed equally well in terms of standing from a seated position and walking. As reported by the authors:19

Significant Risks Found With Short-Term Steroid Use

Aside from the possibility of serious bone loss, other significant health risks have also been found. For example, a study20,21,22 published in The BMJ in 2017, which evaluated data from more than 1.5 million people enrolled in nationwide health care insurance revealed disconcerting effects.

One in 5 patient reports indicated they had filled a short-term prescription for steroids during the three-year study period. Nearly half of those who used steroids were prescribed a "dosepak" where the drugs are prepackaged and labeled for daily use. These "dosepaks," also called "burstpaks," are designed to deliver the highest dose on the first day and taper the dose over the following five days.

In addition to a higher risk of suffering a broken bone, patients who took a short "burst" of steroids also had a higher risk of a blood clot or life-threatening sepsis. This increased risk lasted for up to 90 days after the steroid use had stopped.

The results prompted the researchers to call for better education for physicians and patients about the potential risks. In a press release, lead author Dr. Akbar Waljee said:23

Other Dangers of Long-Term Steroid Use

The dangers of long-term steroid use are well documented. Unfortunately, sometimes physicians and patients believe that steroids are the only option available to reduce painful symptoms. However, the long-term effects of the medication may in many cases outweigh the benefits of treatment, depending on the condition.

Of those who were prescribed steroids in The BMJ study described above, nearly half received the drug for diagnoses related to back pain, allergies or respiratory infections.24 Steroids are also commonly prescribed for other health conditions, including lupus, systemic vasculitis (blood vessel inflammation), myositis (muscle inflammation) and gout.25

The underlying commonality in a majority of conditions for which steroids are prescribed is inflammation. Whether from disease, illness or injury, the intent behind the use of steroids is to lower inflammation, thereby reducing symptoms.

But, steroids are not the only option, and may not be your best option, for lowering inflammation. Since adding hormones (steroids) to your body alters the delicate balance of your natural hormones, the addition can cause a long list of reversible and/or irreversible changes, including the following:26,27,28,29,30,31,32

Steroid Withdrawal

If you do choose to use steroids for an extended period of time, you also need to know that stopping the drug abruptly may trigger adverse and potentially even lethal effects, depending on how long you've been taking the medication. Symptoms associated with steroid withdrawal include:33

Corticosteroids simulate the natural hormone cortisol, released by your adrenal glands. When you add corticosteroids your body has not produced, it may shut down the production of your own hormone.

These changes in the balance to your natural secretion may be the result of taking doses greater than your natural production.34 As you discontinue the drug, you can experience withdrawal symptoms.

These symptoms may be managed through a structured and coordinated drug withdrawal program, to help reduce withdrawal symptoms. The severity of your symptoms will be related to how long you took steroids, the dose and the taper schedule used.35

Safer Alternatives

In specific instances, your medical treatment may necessitate the use of steroids. However, I believe steroids are prescribed far too frequently for conditions that may be addressed with other, much safer options.

In many cases, you may prevent the use of steroids by incorporating lifestyle strategies that naturally reduces inflammation in your body. So, before you resort to steroids, consider implementing a few of the following suggestions first, to see if you can achieve relief: