1 cc Depo-Medrol (methylprednisolone acetate) -- 40mg/cc
4 cc Marcaine (bupivacaine)
Acceptable, but more intense than preferred as the default by the MSK division.
2 cc Depo-Medrol (methylprednisolone acetate) -- 40mg/cc
1 cc Decadron (dexamethasone) -- 4mg
4 cc Marcaine (bupivacaine)
Sometime the referring doctor will express his/her preference.
Some believe it is not advisable to mix the medications together pre-injection as the Depo-Medrol is a suspension and can precipitate with either Marcaine or Decadron. Others suggest that it is actually a good idea to mix the two so as to somewhat dilute the Depo-Medrol before injection.
The preservative in anesthetics will tend to precipitate steroid solutions. Single dose bupivacaine and lidocaine do not contain this preservative and perhaps avoid the problem.
The technologists are to provide separate syringes for the 2 steroids and the Marcaine for those that like to inject the ingredients separately. Hospital policy dictates that techs not mix medications.
A survey of 835 rheumatologists found that 65.9 percent of them (and 74.7 percent of rheumatologists who trained after 1985) combine lidocaine and steroids for injection. (1) Textbooks describing soft tissue and joint injection technique also recommend combining lidocaine and a steroid in the same syringe. (2,3) The package inserts from steroid suspensions caution against mixing the steroid with lidocaine to avoid physical incompatibilities. Flocculation may be seen in the syringe when the parabens in multidose bottles of lidocaine are mixed with steroids. (4)
Although it is theorized that this precipitation may increase the risk of postinfection flare, this has not been proven. Using preservative-free, single-use vials of lidocaine may avoid precipitation in the syringe, but whether this influences the rate of post-injection flare has not been studied. There are several potential advantages to combining lidocaine and a steroid in a single injection. Diluting the steroid in lidocaine may reduce the pain of injection. It also allows the medication to be distributed to a wider area and may decrease the risk of local skin atrophy. The addition of lidocaine to a steroid injection can add diagnostic information as in cases where it is injected subacromially for rotator cuff tendonitis.
Although some concerns about the effect of steroid precipitation on the risk of postinjection flares argue against combining steroids and lidocaine for soft tissue and joint injections, there is no evidence to discourage this common and useful practice.
ANDREW D. SCHECHTMAN, MD, FAAFP
San Jose, CA
Author disclosure: Nothing to disclose.
Pregnancy and breastfeeding are not contraindications to corticosteroids and steroid are sometimes recommended for the carpel tunnel syndrome of pregnancy.
This is a localized reaction to the crystal suspension and s characterized by an increased pain and swelling at the injection site. It is important do differentiate a steroid flare from a septic arthritis. Multidose lidocaine vials contain preservatives that may predispose to precipitate with steroid crystals. Using single dose lidocaine may minimize this