Does anyone Know why certain treatments are being withheld from Shielding patients?

[mikecom1]

Why are my surgery saying that the advice they have is not to give intra-articular steroid injections to shielding patients? What has changed? I used to have these twice yearly and I have been asking; no begging for one for 3 months. I have even offered to pay!

[2greys]

fpm.ac.uk/sites/fpm/files/d...

FPM response to concern related to the safety of steroids injected as part of pain procedures during the current COVID-19 virus pandemic.Introduction. Members have asked questions as to the safety of use of injected steroids for pain procedures duringthe current COVID-19 virus pandemic. Steroid use is common in pain procedures with the aim of easing pain, increasing mobility and quality of life. Their duration of effect is variable but can provide several months of benefit. The immunological impact of steroids given this way in patients with COVID-19 is unknown. As a result of the long quarantine period of an average of 14 days, there is also a risk that asymptomatic patients who are carrying the virus could be treated,potentially putting them at increased risk of an adverse outcome from the virus. There does appear to be higher risk patient groups,notably the elderly and those with comorbidities resulting in higher mortality rates.Moreover, one must consider the risk of admitting patients for elective procedures in a hospital setting where they may be exposed to patients being acutely treated for COVID-19 infection or other illnesses.There is also the risk of hospital staff being exposed to potentially infected patients.Use of steroids in treatment of COVID-19ThecurrentWHO guidance1for the management of severe acute respiratory infection in patients with COVID-19 is not to routinely give systemic corticosteroids unless indicated for another reason.This is because steroids have been associated with an increased risk for mortality in patients with influenza and delayed viral clearance in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Although they were widely used in management of severe acute respiratory syndrome (SARS), there was no good evidence for benefit, and there was persuasive evidence of adverse short-and long-term harm2. A recent study of patients with COVID from China, reports that patients receiving corticosteroids did not have an effect on mortality, but rather delayed viral clearance.3AdviceAs is current practice,injectionsmust not be undertaken in individuals with active infections but the potential arises todo harm to individuals who may be incubating or later develop COVID-19.Long acting, usually insoluble steroid formulations are frequently used in procedures to manage pain. To put this into context,Triamcinolone Acetonide 40mg is equivalent to ten times the normal daily physiological steroid production. Epidural steroids have beens hown to cause a variable degree of adrenal suppression for at least some weeks.4The potential impact of this immunological suppression in a patient incubating COVID at the time or in the future is unknown.

As with all pain management procedures a risk benefit balance has to be reached in discussion with the patient. Each case is unique and no guidance will cover all eventualities.Caution should be used when assessing patients for steroid injections balancing the severity of underlying disease, the potential benefit and the risks including immuno-compromise, underlying comorbidities and further risk should the patient have or become infected in the period after injection when there is likely to be an ongoing effect on the immunological system.Patients should be fully aware of the potential increased risk, the lack of clear evidence and be engaged in decision making. Likewise,individual units should consider the risk and benefits of such injections and under which circumstances they will continue using them during the current clinical conditions. The future.The situation relating to the pandemic is rapidly changing but it is thought that there will be several months of disruption and the potential for a significant proportion of the population to become infected. National guidance should also be followed and will beupdated on a regular, often daily basis.

17March 2020

[mikecom1 in reply to 2greys]

Firstly my surgery announced on Facebook that injections were re-starting last week. Secondly I have recently been tested Covid 19 negative. (my partner is a key worker) Lastly I have been having the treatment for the last 3 years after discussion with my consultant and Physio.

If I am Shielding why did my surgery say it was okay for my partner to return to work? It seems one rule for me and then change them when I need treatment?

[2greys in reply to mikecom1]

In another 3 1/2 weeks the shielding is paused, effectively ends. They are just following their own given advice. Remember GPs are only a medical "jack of all trades" and masters of none. They really only treated coughs, colds, earache, sprains, vaccinations, authorise prescriptions, etc. anything else gets referred to hospital specialists.

[mikecom1 in reply to 2greys]

Thanks for your excellent advice I was hoping that when they relaxed the rules on the 6th of July the surgery would do it then. Obviously they are holding out till the pause on Aug 1st.

[katieoxo60 in reply to 2greys]

Hi 2greys, thank you for the explanation about the pain control. Sorry to invade this post but that explains why my operation is being delayed possibly due to the need for massive pain control needs after the op. I had an incidence prior to lockdown concerning an injection supposedly of steroids given in haste with no advice or the name of the drug. It caused me considerable pain on injection and the drug or what ever did not work my condition has actually worsened. If I had had this information I would not of allowed such behaviour from a hospital doctor. oR reported it to the powers that be. It was not a nice experience but maybe saying it might make mikecom1 think a little more about pain control steroids in the current risk situation. Like him I am sheilding too and as you say only a few weeks to go now before its cancelled. Once Again thank you for detailed post and hope you are keeping well.