Separate Elective Corticosteroid Injections From COVID-19 Vaccination by Two Weeks

By Lisa Rapaport

April 26, 2021

(Reuters Health) - Although there's no direct evidence to suggest that corticosteroid injection before or after an adenovirus vector-based COVID-19 vaccine decreases vaccine efficacy, clinicians may still want to time elective corticosteroid injections at least two weeks before or after receipt of this vaccine, according to a group of doctors writing on behalf of the Spine Intervention Society.

The two-week rule of thumb makes sense based on the known timeline of hypothalamic-pituitary-adrenal (HPA) axis suppression following intraarticular and epidural corticosteroid injections, researchers argue in a paper published in Pain Medicine. Two weeks also makes sense due to the timeline of reported peak efficacy of the Janssen and AstraZeneca adenovirus-vector-based COVID-19 vaccines, the authors also note.

"We know that corticosteroids affect hormonal pathways that modulate the body's immune response," said senior study author Dr. Zachary McCormick, chief of the Spine and Musculoskeletal Rehabilitation Section and director of clinical spine research at the University of Utah School of Medicine in Salt Lake City.

"Studies show that these effects are greatest at one week and to a lesser extent at two weeks following a typical corticosteroid injection for pain indications such as a knee joint injection or an epidural steroid injection," Dr. McCormick said by email.

An early analysis of phase 1-2a and phase 3 trial data found the Janssen COVID-19 vaccine elicited cellular and humoral immune responses and conferred clinical protection as soon as 14 days after administration, while the AstraZeneca vaccine had findings 15 days after the second dose, McCormick and colleagues write.

In the Janssen phase 3 trial, corticosteroid use was allowed at or below the equivalent of 20mg/day via ocular, topical or inhaled administration, the study team notes. Topical or inhaled steroids were permitted in the AstraZeneca trials for up to 14 days.

Early data from studies of these vaccines didn't provide subgroup analysis to determine whether efficacy was reduced for participants who received corticosteroids before or after vaccination, the authors point out.

Clinicians should engage in shared decision making and ensure that patients are aware of the potential interaction with the COVID-19 vaccine so that patients may choose to time any vaccination and elective corticosteroid injections in a manner that's appropriate to their specific circumstances, they conclude.

"It is best if the physician managing the patients' underlying condition review the risks and benefits," said Dr. Fiona Smaill, an infectious disease researcher at Mcmaster University in Canada who wasn't involved in the study.

"Corticosteroids are rarely used for pain control alone but more to treat underlying inflammatory conditions," Dr. Smaill said by email. "When corticosteroids are given locally it is unlikely that there will be a systemic response enough to affect the response to vaccine."

SOURCE: Pain Medicine, online April 11, 2021.