Best Practice Recommendations for Epidural Steroid Injections in a Preservative-Free Dexamethasone Shortage

The Spine Intervention Society released best practice recommendations for the performance of epidural steroid injections in the setting of a preservative-free dexamethasone shortage, which were published in Pain Medicine.

Recommendation 1: The preferred corticosteroid for transforaminal epidural injections remains preservative-free dexamethasone. However, using a dexamethasone-containing preservative can be a reasonable alternative given the paucity of evidence regarding the neurotoxicity associated with benzyl alcohol and the risks associated with using compounding pharmacies to obtain preservative-free dexamethasone.

Recommendation 2: Considering the sterility assurance concerns, physicians electing to use a compounding pharmacy to obtain preservative-free dexamethasone must carefully weigh the risks and benefits and consider the efficacy and safety differences of the multiple access routes to the epidural space.

Recommendation 3: Only nonparticulate steroids should be used for cervical transforaminal injections.

Recommendation 4: Although they are associated with a higher risk, particulate steroids such as triamcinolone, betamethasone, and methylprednisolone may be considered in the absence of preservative-free dexamethasone.

Recommendation 5: Physicians should consider all risk-mitigation strategies if a lumbar transforaminal epidural injection with particulate steroid is performed. Using a particulate steroid will not eliminate the possible effects of preservative excipients, as commercially available particulate steroids do contain preservatives.

Recommendation 6: As there is no evidence of superior safety for one over another, the evidence supports using either particulate or nonparticulate corticosteroids for interlaminar or caudal epidural steroid injections. To balance effectiveness and safety, case-by-case clinical judgment should be used to select the optimal route of epidural injection.

“Physicians should carefully weigh the risks and benefits of using an alternative agent or approach for epidural steroid injection and involve each patient in the process of shared decision-making before proceeding,” concluded the recommendation authors.

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