Methylprednisolone injection site.

[DaveJF]

My (20 y/o, otherwise very healthy) son has some fairly severe seasonal allergies that in turn have lead to nasty sinus infections. After the antibiotics have run their course this time around, the ENT Dr. is recommending an intramuscular injection of something akin to Depo Medrol (Methylprednisolone - Wikipedia, the free encyclopedia) twice per year, right before each allergy season commences. The rational is to keep the inflammation under better control which should help to avoid the recurring sinus infections. Antihistamines and such have not done the job, so basically this is the next step.

The Dr. originally presented the shot as one into the shoulder musculature (front/medial deltoid area), but a little research on that use of that type of drug seems to indicate that it does not have to be done there; only that it needs to be an intramuscular injection.

The reason for the question is that I've had a couple of corticosteroid shots into the shoulder (joint, not muscle) and have been advised that it shouldn't be done a 3rd time due to the catabolic effect this can have on the soft-tissues of the area. I'd hate to see his shoulder(s) causing him problems a few years down the road due to these shots if something as simple as injecting into a larger muscle group and/or alternating muscle groups would help to lower the chance of this.

I'm wondering if you've trained people using the same type of systemic corticosteriod regimen and could suggest a better site for an injection, assuming these shots are to be done twice a year, perhaps over several years?

Thanks.

[Mark Rippetoe]

IM injection and intra-capsular injection are completely different things, and present different problems. While intra-capsular injection is acutely catabolic to the tissues in the contained area of the injection, IM corticosteroid injection is systemically catabolic.

He has had no luck with a combination of nasal steroid spray and oxymetazoline?

[tertius]

It feels terrible to say... but have you considered experimenting with something like hook worms to control his allergic reaction?

[DaveJF]

He has had no luck with a combination of nasal steroid spray and oxymetazoline?

The nasal steroid spray has helped w/ some of the symptoms, and I believe the oxymetazoline will be part of the prescription for acute symptom relief also. As explained to us, the problem is that those do not control the inflammation of the deeper tissues well enough to avoid the blockages that in turn lead to the infections.

I specifically asked about long-term endocrine effects, and the Dr. replied that this treatment has a been around for decades w/ good success rates and a low instance of side-effects, specifically a very low instance of adverse reproductive side-effects (he also didn't know of any in his group of patients). Evidently for this use it is a pretty low total dose released slowly into the bloodstream over the course of a few weeks. He said he's had many of his patients with a problem very similar to our son respond well to the treatment; some of them now going into a couple of decades of use.

[David A. Rowe]

I have suffered from pretty severe seasonal allergies and cat allergies my whole life. It wasn't until this year that I stumbled upon stinging nettle (Urtica Dioica) for treating allergies. I was skeptical at first, but like most old things it turns out to be very effective for most people (and it has a plethora of other health benefits, as well). The plant has histamines that will interrupt the chain reaction of the immune system response. Taken as a tea or a tincture, it typically lasts me about 4 hours. A one pound bag of dried nettle will cost you around 15 dollars off of Amazon (free 2 day shipping with Prime) and can last for quite a while. Greatly reduced my allergy medicine cost (less my typical two nasal sprays and a pill), and has none of the side effects of Benadryl. It may be worth looking into. The only groups I have seen it contraindicated for are people with existing heart/kidney diseases or pregnant women in their first trimester. There are capsules available, as well.

[bugbomb]

IM injection and intra-capsular injection are completely different things, and present different problems. While intra-capsular injection is acutely catabolic to the tissues in the contained area of the injection, IM corticosteroid injection is systemically catabolic.

He has had no luck with a combination of nasal steroid spray and oxymetazoline?

I've gotten the IM steroid shot for vicious seasonal allergies. It seemed to help but the doc swore up and down that nasal spray (fluticasone (Flonase) + ipratropium bromide) would work better. We'll find out next time they attack.

[Mark Rippetoe]

The nasal steroid spray has helped w/ some of the symptoms, and I believe the oxymetazoline will be part of the prescription for acute symptom relief also. As explained to us, the problem is that those do not control the inflammation of the deeper tissues well enough to avoid the blockages that in turn lead to the infections.

My suggestion is that the oxymetazoline be used several minutes prior to the Nasonex, so that the steroid can penetrate to all those hard-to-reach places. The spray must be directed correctly as well, or it will not penetrate.

I specifically asked about long-term endocrine effects, and the Dr. replied that this treatment has a been around for decades w/ good success rates and a low instance of side-effects, specifically a very low instance of adverse reproductive side-effects (he also didn't know of any in his group of patients).

Who is worried about reproductive effects from a catabolic steroid? I'd be worried about the catabolic effects.

[DaveJF]

It feels terrible to say... but have you considered experimenting with something like hook worms to control his allergic reaction?

Along the lines of the "Hygiene Hypothesis"? Funny thing is, both sons have spent a lot of time out of doors and on farms, we've had pets since they were very young, we've raised chickens since they were young, and the younger son has no allergies that we're aware of.

Aside from hookworms making the headlines for things like Crohn's a few years back, I'd be interested to know if there is still active research going on with those.

I have suffered from pretty severe seasonal allergies and cat allergies my whole life. It wasn't until this year that I stumbled upon stinging nettle (Urtica Dioica) for treating allergies. I was skeptical at first, but like most old things it turns out to be very effective for most people (and it has a plethora of other health benefits, as well). The plant has histamines that will interrupt the chain reaction of the immune system response. Taken as a tea or a tincture, it typically lasts me about 4 hours. A one pound bag of dried nettle will cost you around 15 dollars off of Amazon (free 2 day shipping with Prime) and can last for quite a while. Greatly reduced my allergy medicine cost (less my typical two nasal sprays and a pill), and has none of the side effects of Benadryl. It may be worth looking into. The only groups I have seen it contraindicated for are people with existing heart/kidney diseases or pregnant women in their first trimester. There are capsules available, as well.

We actually tried this when he was younger, w/o much luck in his case.

I've gotten the IM steroid shot for vicious seasonal allergies. It seemed to help but the doc swore up and down that nasal spray (fluticasone (Flonase) + ipratropium bromide) would work better. We'll find out next time they attack.

My suggestion is that the oxymetazoline be used several minutes prior to the Nasonex, so that the steroid can penetrate to all those hard-to-reach places. The spray must be directed correctly as well, or it will not penetrate.

I'll advise my son to bring this up with the Dr. before the IM steroid is prescribed during their next appt. Thank you both.

Who is worried about reproductive effects from a catabolic steroid? I'd be worried about the catabolic effects.

That would be me who brought that up in the conversation w/ the Dr., but point well taken on the larger risk here.

[JFord]

My sense of this:

1) ENTs are not necessarily the be all/end all of the treatment of allergic rhinitis and allergic sinusitis unless actual procedures are required. I'd make sure all pharmacologic avenues were explored along with behavioral assessments by an allergy/immunologist. There are some immunologic therapies that can be game changers through getting at the underlying biology of this problem.
2) I wouldn't prescribe systemic steroids unless I'd tried everything else especially in a young guy especially when that treatment is being considered long-term.
3) I'm not aware of any particular advantage of injected steroids over oral steroids in this setting. Rip is completely correct that intrabursal or intracapsular injections have a different set of issues compared to systemc injections (i.e. intramuscular). I will say though that any time one injects steroids into any tissue, there are local issues to be aware of in addition to the systemic effects. Local dermapathy (skin wasting) or myopathy (muscle wasting) can always happen although I personally haven't seen it...yet. A good friend of mine injected a young, very attractive woman's wrist to treat a ganglion cyst and she got a significant myopathy with marked tissue loss that was quite disfiguring to her hand. He never did another steroid injection in his career.
4) I've personally not heard of using systemic steroids in a patient that wasn't currently experiencing symptoms but that may just be me. I've only ever considered it in exacerbations where my patient was miserable and we had to do something NOW.

My two cents.

[tertius]

Along the lines of the "Hygiene Hypothesis"? Funny thing is, both sons have spent a lot of time out of doors and on farms, we've had pets since they were very young, we've raised chickens since they were young, and the younger son has no allergies that we're aware of.

That's quite peculiar.

Aside from hookworms making the headlines for things like Crohn's a few years back, I'd be interested to know if there is still active research going on with those.

There definitely is, though not all of it is professional or academic. If I have time in the next few days I'll see if I can dig anything up.