title: Use of a Risk-Stratification Tool in Identification of Potential Adrenal Suppression Preceding Steroid Injection Therapy in Chronic Pain Patients.
abstract: BACKGROUND
  Patients who present for steroid injections are not routinely screened for potential hypothalamic-pituitary-adrenal (HPA) axis suppression from previous steroid exposure. Patients often receive various steroid therapies that are not reported by the patient or recorded in available medical records. Yet, HPA axis suppression has been reported with a single intra-articular injection.
  
  
  METHODS
  An IRB-approved quality improvement questionnaire was implemented to comprehensively screen patients for risk of HPA axis suppression secondary to prior and/or concurrent corticosteroid use. This questionnaire was given to adult patients seen in a University Pain Management Clinic, who were being considered for a steroid injection, to define the extent of exposure to corticosteroids either by mouth, topically, inhaled, or systemic/local injection within the past 6 months.
  
  
  RESULTS
  Two hundred patients completed the questionnaire. Eighty-nine patients (44.5%) screened positive for significant steroid exposure with a screen score of three or above. The average score for the screen positive group was 6.31 ± 3.47 (range 3-22). Women were 1.9 times more likely to screen positive than men (53.4% vs 27.5%, P < 0.0004). Otherwise, the screen positive and screen negative groups were similar in demographic characteristics (age, BMI, and diabetes status).
  
  
  CONCLUSIONS
  Our results suggest that patients receive steroids from many sources and may be at risk for HPA axis suppression. Further testing is necessary to determine if these patients indeed have biochemical evidence of adrenal suppression. Utilization of a screening questionnaire might help identify patients who should be considered for HPA axis testing prior to steroid injections.
authors.affiliation: University of Virginia School of Medicine.
authors.forename: Aneesh Paul
authors.initials: AP
authors.lastname: Goel
authors.affiliation: University of Virginia School of Medicine.
authors.forename: Vu Huy
authors.initials: VH
authors.lastname: Nguyen
authors.affiliation: Department of Anesthesiology, Division of Pain Medicine, University of Virginia Health System, Charlottesville, Virginia.
authors.forename: Robin
authors.initials: R
authors.lastname: Hamill-Ruth
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000009:adverse effects; D000309:Adrenal Insufficiency / Q000139:chemically induced / Q000453:epidemiology* / Q000517:prevention & control; D015984:Causality; D059350:Chronic Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology*; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000187:drug effects; D015995:Prevalence; D016016:Proportional Hazards Models; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods*; D012680:Sensitivity and Specificity; D012984:Software; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014768:Virginia / Q000453:epidemiology
chemical_list: D000305:Adrenal Cortex Hormones
keywords: Chronic Pain; Corticosteroids; Hypothalamic-Pituitary-Adrenal Axis; Screening Questionnaire; Secondary Adrenal Insufficiency/Suppression; Steroid Injection