Do You Need a Lower Epidural Steroid Dose if You Have Diabetes?

by LMatthews on October 14, 2014

epidural steroids and diabetes in spinal stenosisEpidural steroid injections for back pain have long been a popular way of treating spinal stenosis related to inflammation in the lumbar spine. The safety of these injections has, especially in the past couple of years, been called into question numerous times, and one such concern is the documented effect on blood glucose that occurs after epidural steroid injections.

Should people with diabetes receive epidural steroids at all? Could a lower dose work just as well and reduce the safety concerns? Research published late last year says that a reduced dosage looks like the right way to go to manage back pain in those with type 2 diabetes.

Back Pain and Diabetes

Lumbar degenerative spinal diseases are frequently accompanied by type 2 diabetes (mellitus), partly because the two conditions are quite common and possibly because back pain can indirectly increase the risk of diabetes (through reduced exercise, for example), while diabetes can increase pain sensitivity, nerve damage, inflammation and tissue degeneration.

It is fairly well known that epidural steroid injections increase blood glucose levels, and in this study this effect was significant and persisted for up to four days after the procedure in patients with well-managed diabetes. Higher doses (40mg) of the steroid triamcinolone increased fasting (FBG) and postprandial (after-meal) blood glucose (PBG) more than a lower dose (20mg) of the drug, but the researchers found that the lower dose of the steroid fared no less well for pain control.

This trial involved 100 patients with diabetes mellitus who were also suffering from radiculopathy, spinal stenosis, or failed back surgery syndrome and who were to undergo treatment using lumbar transforaminal, lumbar interlaminar, or caudal epidural triamcinolone. The patients were randomised to receive either the low dose (20mg) or high dose (40mg) treatment with triamcinolone and the patients were asked to measure their finger stick blood glucose level twice daily (fasting and postprandial) for 3 days prior to their epidural injections, on the day of treatment, and for a week after the treatment. They were also asked to record their FBG and PGB 14 days after the injection. Patients were also evaluated at 8 weeks after the procedure for their employment status and clinical outcome.


The Results

For those receiving 40mg of the steroid (compared to 20mg) there were:

  • Significant increases in FBG on the first day after the procedure
  • Significant increases up to day three after the procedure
  • Significantly elevated PBG from the day of the procedure to three days afterwards
  • Significantly greater increases in PBG on the day of the proceudre and the first day afterwards
  • Significantly greater increases in FBG on day one and day two after the procedure

Those in the 20mg group also had significant elevations in PBG from the day of the procedure to day three after.

In both groups, subjective pain assessment decreased for up to 14 days after the epidural steroid injections, and there was no difference in pain relief between the higher and lower doses of triamcinolone. Nor were there any differences in employment status or clinical outcome at 8 weeks after the epidural steroid injections.

Some issues with this trial include the potential for the steroid to be differently absorbed into systemic circulation when injected at different locations in the spine and in different conditions. For example, people with failed back surgery syndrome (FBSS) may have reduced or slower absorption than patients without FBSS due to changes in the epidural space caused by surgery and post-surgical scarring.

This trial does lend support to the idea that patients with diabetes may experience as significant relief of symptoms of back pain, leg pain, and other symptoms of spinal stenosis, FBSS, and radiculopathy with a low dose epidural steroid injection instead of a higher dose, and that this may be better for supporting healthy blood glucose control following epidurals.

Reference

Kim WH, Sim WS, Shin BS, Lee CJ, Jin HS, Lee JY, Roe HJ, Kim CS, Lee SM. Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus. Pain Physician. 2013 Nov-Dec;16(6):557-68.

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