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03/15/2014 Bryan C. Markinson, DPM
Post-Injection Heel Complications (Lawrence Oloff, DPM)
I appreciate Dr. Oloff's response to my recent post and thank him for his kind reflection about my prior posts. I have also received several private e-mails from colleagues expressing intense disagreement with my contention that soluble steroid preparations have no utility in podiatric musculoskeletal treatment. However, it seems as though my remarks were interpreted as if I stated that it is wrong or inappropriate to use soluble steroids. I had no such intention.
In support of Dr. Oloff's charge that my information is innacurate, he states that he knows rheumatologists who use the soluble preparations, which in part is a retort to my observation that the orthopods and rheumatologists that I know never use them. Obviously, I did not and do not mean to speak for all rheumatologists and orthopods.
In further support of his opinion, Dr. Oloff cites in part a reference which states the following: "A short-acting solution, such as dexamethasone sodium phosphate (Decadron), is less irritating and less likely to cause a postinjection flare than a long-acting dexamethasone suspension. "
Well of course! 65% of the injected dose is excreted in the kidneys within 24 hours. Locally, the solution is dispersed within one hour. The kinetics may be a little different with intra- articular injections, but not much different.
Because of this, I conclude that there is no utility and the effects that everyone talks about (in combination preparations) being that the short acting preparation works by providing relief until the insoluble takes effect is close to a fantasy (IMHO). Even if I am dead wrong, I would argue that the local anesthetic injected with the cocktail is just as good as the soluble steroid, but no way does either the soluble part or the anesthetic give you the 24-48 hour window often needed for the insoluble to "kick in."
I encourage all of my colleagues to continue to use soluble steroids alone or in combination if they believe that they are efficacious. My own opinions that the use of soluble preparations seem wasteful is only my opinion, for your consideration only, and not a critique of anyone who finds them useful. I apologize for any other unintended impressions.
Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org
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