Guest: Dr. Joseph Bax

Corticosteroid injections are everywhere in musculoskeletal medicine. Epidurals, joints, facets, bursae: when inflammation and pain are the targets, steroids have long been one of the sharpest tools in the shed. But does local treatment mean only local consequences? And when does another shot become one shot too many? In this episode of the JDD Podcast Corticosteroid Stewardship Series, host Dr. Adam Friedman sits down with Dr. Joseph Bax, an interventional physiatrist and Assistant Professor of Orthopedics and Rehabilitation and Human Performance at the Icahn School of Medicine at Mount Sinai, to inject some perspective into procedural corticosteroid use.

The two take aim at the when, where, why, and how often of corticosteroid injections: Who is the right patient? How much is too much? Perhaps most importantly, who is keeping the steroid scorecard when one patient gets an epidural from one physician, a joint injection from another, oral prednisone somewhere else, and a topical steroid from…well, you know who? From cumulative corticosteroid exposure and comorbidities to physical therapy, radiofrequency ablation, nerve blocks, PRP, and other steroid-sparing strategies, Drs. Friedman and Bax explore how to reduce reliance without replacing evidence-based medicine with wishful thinking. So before you say, “Just give ’em another shot,” give this episode a gander. Good corticosteroid stewardship isn’t about taking the needle away, it’s about the right shot, right patient, right time, and right reason.

 Introduction and Steroid Exposure

:47

Dr. Adam Friedman: 

Welcome to the podcast, Dr. Joseph Bax.

Dr. Joseph Bax

Thank you very much, excited to be here.

Dr. Adam Friedman

Yeah, I have so many questions for you because you know in looking at your bio, your CV, you know you really span across many different areas of orthopedics rehab even I’d argue probably pain medicine and across that spectrum, I imagine corticosteroid injections are probably somewhat too deeply embedded I think they could probably provide meaningful relief potentially help patients avoid surgery. But I guess my first question before we really dive into the utilization of corticosteroids in your area. You know, I think local doesn’t necessarily mean biologically inconsequential. And I’m curious if in your area, in your specialty, are is corticosteroid exposure underestimated simply because you are injecting into a joint space, you’re injecting locally, rather than prescribing oral steroids, for example?

Dr. Joseph Bax

Yes, you’re absolutely right. So as you mentioned, you know in my specialty, physical medicine and rehabilitation and interventional physiatry where the mainstay of my practice is injections into our joints, around nerves, into around tendons, in the epidural space.The majority of the corticosteroids that I use are injection-based, however. there are situations where a patient maybe doesn’t want an injection for one reason or another, or we just can’t set up an epidural on the spot where we have to wait for insurance authorization you know they’ll come in maybe asking for an oral corticosteroid, like a Medrol Dosepak or a prednisone taper. So those are other instances where I do use orally prescribed or my partners will use orally prescribed steroid medications to help maybe calm down a pain flare, whether it be their knee or their back or their shoulder. So like you mentioned, the yes, the majority are definitely by injection, but I am familiar with the oral dosage as well.

Steroid Familiarity and Side Effects

4:21

 

Dr. Adam Friedman

You know, I think in dermatology, we often talk about corticosteroids. They’re incredibly effective, you know, especially in the acute setting, especially topically, that’s such a big part of our wheelhouse. And I think that familiarity can sometimes make us a bit too comfortable with them it’s just easy to kind of send off another refill of a one pound jar of triamcinolone sometimes do you feel it’s a similar phenomenon in your area in your space like interventional pain medicine where it’s just such an easy quick fix that people reach for it so easily without considering potentially the bigger and maybe compounded consequences.

Dr. Joseph Bax

I do. You’re right. The steroids work and they’re very effective. But they have side effects that you have to be aware of especially you know in my field specifically yes it’s easy to set up an injection and perform my steroid injection and patients feel better their joint or their back their pain feels better And then they also sometimes get that added benefit of maybe having a little bit more energy or being a little bit more productive, which is you know they see as like a little bit of a bonus. But you have to be careful and cautious of some of those other side effects that can happen like the increase in blood sugar or the a mania episode or watching their bone health. So you have to be vigilant. You have to be cautious. You don’t want to overutilize anything. And it’s always the you know the lowest effective dose and as infrequently as possible to help balance that you know pros and cons of how effective steroids are.

Dr. Adam Friedman

And almost I know that you are certainly interested in corticosteroid stewardship. I’m curious, you know, in terms of your humble beginnings in this area. Was there a particular patient or a recurring clinical scenario that changed the way you thought about, to your point, those repeated easy to reach for corticosteroid injections?

Dr. Joseph Bax

There was actually. So when I was in residency I was rotating through the pain clinic where we had a fellowship,  seeing a patient with the fellow. And, you know, it was your typical sciatica patient, who was ready to set up another epidural steroid injection to calm down the pain. We present the case to the attending. We go back into the room, evaluate the patient. He’s taking a little bit more thorough history. And as it turns out, the patient has had about you know but I can’t remember maybe four or five epidurals within the last couple months on top of a couple oral dosages of steroids. And then, you know, looking at the patient, you start to realize the moon facies. You start to realize the buffalo hump. You start to realize the central adiposity. So the, you know, the attending, to his credit, recognized that, you know, changed the course to more physical therapy, getting them enrolled with endocrinology, taking a steroid holiday just to help you know offset and take a little break to help reset that clock and to help avoid you know furthering those complications so I was lucky in the sense that I was exposed to that early in my training. So I tried to be more aware of those side effects and consequences so as to not get to that situation because yes you know somebody’s pain definitely needs to be addressed and treated but not necessarily always with a steroid.

Tracking Cumulative Corticosteroid Burden

7:29

Dr. Adam Friedman: I mean, I think you kind of almost refer to the steroid ledger, right? So, you know, how are we making sure that even in our own specialty we’re keeping track of how much someone’s getting through one pathway but then you know from your perspective you know obviously a patient may receive an epidural multiple epidural injections from you and then a joint injection from someone else prednisone from primary care inhaled steroid from pulmonary the list goes on and on. I think that there there is definitely a gap when it comes to keeping track of that cumulative burden and I think that there’s really not a great way to approach that and I think your story absolutely highlights that issue so just curious in your own practice, how do you Keep that ledger in terms of ensuring that you’re not number 13, lucky 13, right, for for that patient with epidural?

Dr. Joseph Bax: Right. You’re absolutely right. So I definitely keep a tally on my end, just from the injections that I perform. And not all injections are with steroid, but obviously the ones that are, we want to monitor and we want to you know keep note of. And I always have to ask the patients too, like you mentioned, they have other conditions, they’re seeing other doctors. Did they get a steroid pack for their bronchitis recently? Or were they prescribed something for their rash recently or as for their asthma or for their Crohn’s disease? So, you know, our time is limited and we want to be as efficient as possible. But to ask a couple more of those questions just to see, you know, oh, I just saw the orthopedist and got a shoulder injection. I’m going to schedule my epidural for next week, you know, have that conversation and just be a little bit more inquisitive. So do my due diligence on my end to help keep track of the dosing and the frequency. And then it’s hard, but luckily within our hospital system, we can connect with the other providers pretty easily. And I could see their notes or send them a… you know, my chart message, just to let them know what’s going on. And the other physicians really appreciate that. The patient really appreciates it. And it’s you know they’re better off in the long run.

Dr. Adam Friedman: I think also, you know, and when we think about steroid stewardship, sometimes we get some pushback. And I think everything you’re suggesting – should be integrated especially with EMRs nowadays should be very simple to do in a health system it’s a little easier to follow but I also don’t want us to say oh all steroids bad you know need to you know kind of like lambaste our colleagues across the aisle because I think it is the right drug for the right patient at a right moment and so maybe to kind of pivot a little bit let’s think about who would be an excellent candidate for a corticosteroid injection you know I think especially as dermatologists if we see that patient because patients come in, they’re told they’re getting a full body in their heads, it’s not a skin cancer evaluation. It’s literally, we’re going to talk about the full body.

Dr. Joseph Bax: Mm hmm.

Dr. Adam Friedman: You know when we hear about every ache and pain and itch, Are there classic candidates that you think would be appropriate for a steroid injection? And on the flip side, what would immediately make you pump the brakes on considering that in terms of an epidural or with steroid or, you know, a joint space injection?

Dr. Joseph Bax: Sure. So yes, if a patient in my field specifically, if a patient comes in with an acute radiculopathy, very severe pain. The MRI is consistent with their symptoms. They have a lot of inflammation, irritation on that nerve. The more conservative, and over-the-counter anti-inflammatories, physical therapy is not helping. They’re miserable. They can’t sleep. They can’t walk. That’s a great candidate for an epidural steroid injection. They do quite well. Sometimes it does take a second injection just to really calm down that inflammation. So I wouldn’t hesitate to do an injection as quickly as possible with steroids, which is very effective, and then assess reassess them, see how they’re doing, and potentially repeat that as soon as a few weeks later, if necessary. Same thing with if a severe joint inflammation or arthritis flare-up that’s happening in somebody. It’s interfering with their functioning they can’t lift, they can’t sleep they can’t work um my goal as a physiatrist, you know, is to keep somebody as functional and minimize their pain as much as possible, uh, to answer your second question, you know, but you want, it’s a balance. So you don’t want to overdo anything either. So if you realize that a patient’s had maybe two, three epidurals in a very short period of time. as that. you know it’s not helping it’s not getting them where they need to be then maybe you need to you definitely need to reassess potentially the diagnosis or do some more testing or imaging just to help to see maybe there’s something else going on and the steroid isn’t the answer.

Dr. Adam Friedman: Are there certain comorbidities or demographics? I mean, so go back to comorbidities, diabetes, osteoporosis, hypertension, or even, for example, older adults. Are there certain things in the patient’s story that jump out at you in terms of how you approach stewardship versus those who don’t have comorbid diseases?

Dr. Joseph Bax: Yes. And you hit on a couple of them actually. Diabetes is a one that I take note of specifically. I definitely would ask if they’re, you know, type 1 or type 2, how their sugars are controlled, what their A1C is, how their sugars run usually. And I tell them ahead of time, sometimes patients realize, sometimes they don’t. But the steroids are going to increase their blood sugar. And if you’re diabetic, it’s going to increase it potentially significantly, especially if they’re poorly controlled. so obviously with elevated glucose long-term, it increases risks of infection and other things. So we want to be very cautious. And if somebody is a very poorly controlled diabetic, I would be hesitant, or definitely would want to loop in their endocrinologist and make sure they have their appropriate medications on hand to manage that increase of blood sugar appropriately, in the short term. And also with osteoporosis, long high-dose steroids long-term can break down bones. So we want to be cautious with that and make sure that they’re either, plugged in or getting treated or monitored from an osteoporosis perspective so as to not exacerbate that at an advanced rate.

Patient Communication and Managing Expectations

13:30

Dr. Adam Friedman

Before we switch gears to the steroid sparing toolbox, I would love to hear how you handle the patient who says, Just give me a shot. You know, that patient who’s like, Doc, I don’t need this whole discussion. I don’t need any tree hugging. Just give me the shot, it worked last time.How do you handle that conversation for the patient who wants that? Because this is relevant for many specialists, especially DERM, who want that Medrol or even worse, like they want a taper starting at prednisone 50, for example, or they want another jar of triamcinolone.

Dr. Joseph Bax

Right.

Dr. Adam Friedman

This translates across all specialties.

Dr. Joseph Bax

Right.

Dr. Adam Friedman

How do you handle that conversation?

Dr. Joseph Bax

Yeah, so you’re right. So, Doc, I know this works. Just give it to me. It worked last time. I’m ready to go. And, you know, they have a point, you know, yes, these are effective and they work and the patients benefit from them. So it’s a conversation. I say, listen, this is definitely an option. We can certainly proceed with the injection, but be aware, you know, these are the risks. These are the side effects. These are the benefits. We want to be cautious moving forward. And we want, you know, we could do this, do the injection, you know, now, but, you know, moving forward, this gets you plugged into the therapy or try some other modalities. So maybe you don’t need the injection as often or you know this injection potentially lasts longer.So it’s everything in combination. I tell my patients regularly, it’s not one shot or one pill or one session of physical therapy that quote unquote fixes this issue we have to attack it from all angles.

Dr. Adam Friedman

Right.

Dr. Adam Friedman

And what are some of the consequences you talk about? So as in this case, right, the patient’s like, I don’t want to hear your whole story. Just give me a shot. What are some of the consequences that you see that we as dermatologists need to know about when we’re saying, oh yeah, you need to go get that injected. You need an epidural. What are things that we should probably set the stage with in terms of? Possible adverse events. maybe from a one-time or one-off or even, to your point, from longitudinal exposure, obviously depending on where you’re injecting, of course.

Dr. Joseph Bax

Yeah.

Dr. Joseph Bax

Sure. Sure. So yeah, I’ve actually over the years, I’ve kind of, anytime I offer an injection, we talk about an injection or decide to proceed with one, always talk about the risks, benefits, side effects. And I kind of make it my routine now to always inform the patients that it’s you know not always going to happen but it’s possible after you receive the steroid injection You might feel some heart palpitations. You might feel a little flush. You might feel a little wired. You might feel a little jittery. Your appetite might increase. You might be a little irritable. So that they’re either prepared, you know, so because I’d rather tell them ahead of time, proactively, then get that phone call the next day or the day after.

Dr. Adam Friedman: Right

Dr. Joseph Bax

Oh my goodness, what’s going on? Do I need to go to the ER? So if they’re, obviously they could still call me afterwards by all means. But it’s better to have that conversation early so that they’re aware of it. So they don’t think that there’s a problem or a complication because these are very, you know, we see this pretty commonly. We’re using a good dose of steroid to treat the issue and everybody responds and has a different tolerance to the side effects. So those are just the education aspect of it. Just to give them a little bit of that information ahead of time, I find goes a real long way.

The Steroid-Sparing Toolbox

16:30

Dr. Adam Friedman

All right, let’s move into something I’m very excited to hear about from your perspective the steroid sparing toolbox and and while cyber stalking you you know I noticed your practice incorporates a wide array of really cool steroid sparing approaches physical therapy as you mentioned you know osteopathic manipulation radio frequency ablation nerve block spinal cord stimulation lots of different things um would love with the corticosteroid stewardship hat on what are some of the most useful alternatives for reducing repeat steroid exposure without under treating the pain because I find that’s often an issue is you know we say well you’re not going to want that and I feel like the the opioid kind of story is is almost somewhat analogous.

Dr. Joseph Bax

Mm-hmm.

Dr. Adam Friedman

It’s like, oh, no, you don’t want that. We’re going to give you this. But then often that may be undertreating or under addressing the problem. What do you find strikes a good balance outside the world of steroid injections?

Dr. Joseph Bax

Sure, absolutely. So obviously, different medications that you mentioned. There’s the non-steroidal medications, which we’re all familiar with. There’s the neuropathic agents like the Lyricas and the Gabapentins. There’s muscle relaxers just from a medication standpoint. from a physical therapy acupuncture chiropractor in our era in our office we’re lucky to have and on staff chiropractor and acupuncturist which is great patients respond really well to that um I could communicate with her regularly to help update her and treat our patients from different injections that we do, which aren’t necessarily steroids. Like you mentioned, medial branch blocks, which are just diagnostic injections. Followed by radio frequency ablations where we can heat up and burn some of those pain transmitting nerves and that gives you relief longer term over the course of eight to ten months spinal cord stimulation you know in a nutshell is basically like electricity that we’re delivering to the spine to block that pain signal centrally. And another thing that we’re developing and utilizing more and more is platelet-rich plasma therapies and bone marrow aspirate concentrate therapies to help replenish and heal and rejuvenate some of these damaged tissues especially in like the arthritic conditions and the tendinopathies which is your body’s own substances which has been shown to help give you longer lasting benefits without those steroidal side effects. So like there’s a lot of other options in addition to steroids, which is pretty exciting.

Dr. Adam Friedman

Yeah, no, it sounds like it, I think there’s obviously the things we are going to hand off to you and other colleagues in your specialty. You know, you mentioned some of my favorite oral therapies to address pain that aren’t opioids, like gabapentinoids for example I’d love to maybe dive a little bit more in terms of how you utilize whether it be gabapentin or pregabalin amitriptyline

Dr. Joseph Bax

Mm hmm.

Dr. Adam Friedman

even SSRIs, because I think that… They are so in reach but I think so many unless you actually have someone looking over your shoulder guiding you to dose escalation and then possibly de-escalation or you’re using them in your residency where you’re protected in that wonderful envelope from your attendings you may not reach for it so I’d love to hear some of the ways you use it and how you approach to that escalation and kind of if there is any monitoring

Dr. Joseph Bax

Sure. No they work very well you’re right And it’s a you have to be comfortable prescribing them and dosing them and escalating them and then potentially weaning them off if they’re not effective. And they have added benefits too, you know, in the sense that they work really well for some of the neuropathic pain situations that we see sometimes there’s they are sedating so you have to be aware of that but so that’s why we typically dose them at nighttime. Because if they have a when you’re in pain, sometimes you have difficulty sleeping. So you can get that added benefit of improved sleep, especially when you’re in a pain situation. I always ask the patient just their history. Have you tried this before? What was the effect? Some patients would say. Gabapentin worked great for me. I had to use it before or I gave it to my dog. I hear every so often.

Dr. Adam Friedman

Right. Yeah, I’ve heard that too. ah

Dr. Joseph Bax

Oh, I know. I have some of that at home. Can I use that? I said, I’ll give you your own.

Dr. Adam Friedman

Right.

Dr. Joseph Bax

You can let your dog keep yours. But I find that they work very well. Or if somebody maybe has failed gabapentin first, then I would maybe go to pregabalin. Or maybe a like a duloxetine. And then the tricyclics to work very well. But you want to address their comorbidities. If they have a cardiac issue or in the elderly, you want to be a little bit more cautious because of the sedation side effects or the urinary retention side effects. So it is a balance. And you want to start low, go slow, titrate gradually. Warn them of the side effects of maybe the dry mouth. So that way they’re aware and then you can, you know. adjust or wean them down as appropriate

Dr. Adam Friedman

I love it. I use that mantra all the time. Go low and slow. I totally agree.

Dr. Joseph Bax

That’s it.

Dr. Adam Friedman

And with gabapentin you do, because I think that you can start low, but they do get this. I don’t want to say tachyphylaxis, but they do get kind of used to it. And you do have to dose escalate. And fortunately, the ceiling is relatively high. I mean, you can go as high as 3,600 milligrams a day. But your point in the elderly. that could be very problematic. The sedation effects can be really impactful not to mention even sometimes it has a Paradoxical like hyperactivity that’s seen occasionally so so it is gonna be very person dependent I mentioned this before and I love maybe your take on this, you know, I think pain medicine has already lived through an enormous stewardship reckoning with opioids.

Dr. Joseph Bax

Yes, mm-hmm

 

Lessons from Opioid Stewardship and Interdisciplinary Care

22:00

 

Dr. Adam Friedman: What lessons are there to learn from that that we can apply corticosteroids before we find ourselves kind of correcting another pattern of either therapeutic over-reliance or and more what I’m seeing now is complete avoidance you know I think people are scared to prescribe opioids and I think it’s all about meaningful use you prescribe them when they’re appropriate but it’s the pendulum has completely swung and I think. Really, we have to be careful with these approaches to stewardship that we don’t overdo it. So what, what things have you seen that have changed over time that we can maybe employ for steroid stewardship?

Dr. Joseph Bax

You took the words out of my mouth. Yes, the pendulum has definitely swung, even since when I finished my fellowship in 2011. The landscape has definitely shifted you know pain as a fifth vital sign you treat pain until they don’t have it anymore, escalate as needed and it was it was definitely the times have definitely have changed. And you’re right, sometimes physicians are a little bit scared or more hesitant to prescribe because of those. because of that situation. And there’s an analogy with steroids as well, because they do have side effects. And obviously, it’s not and from an addiction from a purely addiction standpoint, like it could be with a strong opiate, but just from a that they’re helpful in the sense that patients sometimes are coming in and requesting them, per se, because they do work. But like you mentioned, you want to be vigilant. You want to be cautious. You want to be conservative. But at the same time, you also want to help the patient. So you want to be able to do what you think is best, you know, on a case-by-case basis. Have the conversation with the individual, what the goal your goal of care is, what the realistic expectations are. Yes, I want to get rid of your pain completely, but realistically.

I want to keep it as minimal manageable as possible. You’ve been dealing with this for a long time. So we’re going to do everything that we can to keep you as functional and active within the means to keep you also safe. So you really just want to be comprehensive and have a good line of communication with the patient. to make sure that we’re all on the same page.

Dr. Adam Friedman

So you know This podcast series has very intentionally brought together clinicians from different specialties because corticosteroids do not respect any boundaries. Dermatology, gastroenterology, rheumatology, pulmonology, many others that prescribe corticosteroids. What do you think we could all learn from pain medicine from a lot of things that we’ve talked about with respect to procedural steroid use? What are lessons that we may be missing that you only get from your experiences?

Dr. Joseph Bax

Yeah, I would say you know use this as a resource. You know, we’re here to help. So yeah, this is a great, this stewardship program is great because as you mentioned, it presents so many different specialties and medicine is so fragmented in the sense that everyone has their very narrow scope at times, but there is a lot of overlap. So we could all work together to help treat, you know, our specific things directly. But at the same time, you want to have a balance and you want to have open communication so that we can do what’s best for the patient. And from a, pain management perspective, whether it’s a shoulder or a hip or a knee or, a psoriatic arthritis, which is affecting the spine, but potentially also the joints in their skin you know the work side by side I think is just just a great option for our patients

The Bax Bottom Line

25:15

Dr. Adam Friedman

Well said. So I want to wrap up with some rapid fire questions that I, because I love alliterations, that I’m going to call the back’s bottom line. So some quick questions.

Dr. Joseph Bax

Great.

Dr. Adam Friedman

I want your… From the hip, shoot with an answer. So the first one is, what is the biggest biggest misconception clinicians have about corticosteroid injections?

Dr. Joseph Bax

That every injection we give is a corticosteroid. So just because we’re giving the patient a shot per se, it’s not necessarily a steroid shot. So I think that is one thing that I think it’s a little misunderstood, that I think could be clarified.

Dr. Adam Friedman

Complete this sentence, a corticosteroid injection is successful when…

Dr. Joseph Bax

When given to the right patient.

Dr. Adam Friedman

Well said. Complete this one. I start worrying about corticosteroid overuse when…

Dr. Joseph Bax

When patients are having detrimental side effects.

Dr. Adam Friedman

For the clinician listening who performs corticosteroid injections routinely, what is the one question you hope that they are asking themselves before the needle goes in?

Dr. Joseph Bax

How many injections have they gotten recently of steroids?

Dr. Adam Friedman

And finally, last one, if there’s one message you want our listeners to take away about corticosteroid stewardship in pain medicine, what is it?

Dr. Joseph Bax

Steroids work. They work in the right patient and they work in the right situation. And like anything in medicine and in life, you have to just be careful and be conscious of the risks, benefits and alternatives.

Dr. Adam Friedman

Well, well said and well played with the Bax bottom line. Dr. Bax, thank you so much for joining us for this edition of the Corticosteroid Stewardship Series of the JDD Podcast. I’m sure our audience learned a lot. And I think you hit on something so important. and kind of part of the mission of all this is you’re not alone we have colleagues across many different aisles who have really interesting ways to address in this case patient pain functionality that may not need to sacrifice safety with respect to current steroid injections so knowing that knowing what’s out there and knowing who’s out there, I think is very relevant. And that’s really the point of us being here. So I thank you so much for sharing your expertise and insight with the audience of the JDD podcast.

Dr. Joseph Bax

Thank you so much for having me and thank you to you and for doing this podcast and shedding light on such an important subject. You’re doing tremendous work and I appreciate it.

Dr. Adam Friedman

Thanks so much. And thank you all for joining us for this edition of the JDD Podcast.