391 - Two COVID Vaccine Cautions, Joint Injection Tips
Take 3 – Practical Practice Pointers©
From the CDC and a Question from a Colleague and Patient
1) Coadministration of COVID Vaccine with Other Vaccines
Is it safe to have other vaccinations administered around the time of a COVID vaccine?
None of the currently authorized COVID-19 vaccines are live virus vaccines. Because data are lacking on the safety and efficacy of COVID-19 vaccines administered simultaneously with other vaccines, the CDC recently released recommendations that the vaccine series should routinely be administered alone, with a minimum interval of 14 days before or after administration of any other vaccine. However, COVID-19 and other vaccines may be administered within a shorter period in situations where the benefits of vaccination are deemed to outweigh the potential unknown risks of vaccine coadministration (e.g., tetanus-toxoid-containing vaccination as part of wound management, rabies vaccination for post-exposure prophylaxis, measles or hepatitis A vaccination during an outbreak) or to avoid barriers to or delays in to COVID-19 vaccination (e.g., in long-term care facility residents or healthcare personnel who received influenza or other vaccinations before or upon admission or onboarding). If COVID-19 vaccines are administered within 14 days of another vaccine, doses do not need to be repeated for either vaccine.
As with much surrounding COVID and the COVID vaccine, this is an area that will continue to evolve as we learn more about the vaccines. Note as well that American Society of Interventional Pain Physicians (ASIPP) presently recommends that if patients receive short-acting steroids, such as dexamethasone and betamethasone, a 2-week waiting period before vaccination may be appropriate. If long-acting steroids, i.e., methylprednisolone or triamcinolone, of 80 mg or greater, it may be appropriate to wait at least 4 weeks prior to the vaccination to avoid any interference. They also recommend that after vaccination, interventional pain procedures with steroids should be delayed for two weeks after the second or final dose of the vaccine.
- CDC: Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. 5 March 2021. Link
- ASIPP Guidance on COVID-19 Vaccine and Steroids: 22 January 2021. Link
From the Literature
2) Axillary Adenopathy and COVID vaccine
Unilateral hyperplastic axillary nodes can be seen on sonography after any vaccination but are more common after a vaccine that evokes a strong immune response. As the differential of includes breast malignancy, it is crucial to both thoroughly evaluate the breast for primary malignancy and to elicit a thorough history.
With the approval and rapid deployment of the COVID-19 vaccines, many of the potential downstream consequences are only beginning to be appreciated. One recent caution concerns the presentation of unilateral axillary adenopathy in the post-COVID vaccination patient at a rate that appears significantly higher than that for most vaccines. It therefore becomes imperative to consider COVID vaccination history in the differential diagnosis of unilateral axillary adenopathy, and also consider the timing of breast imaging with regard to the COVID vaccine.
Given this risk, the Society of Breast Imaging recently published some guidance regarding breast imaging and the COVID-19 vaccinations. Recommendations include:
For patients and providers scheduling screening mammograms:
- If possible, and when it does not unduly delay care, consider scheduling screening exams prior to the first dose of a COVID-19 vaccination or 4-6 weeks following the second dose of a COVID-19 vaccination.
For patients having a screening mammogram:
- Consider obtaining the following information on patient intake forms: COVID-19 vaccination status, timing and side (left vs. right arm) of vaccination. To minimize patient anxiety, consider including this introductory statement: Vaccines of all types can result in temporary swelling of the lymph nodes, which may be a sign that the body is making antibodies in response as intended.
- Following appropriate diagnostic work up for unilateral axillary adenopathy in women who received a COVID-19 vaccination in the ipsilateral upper extremity within the preceding 4 weeks, consider a short term follow up exam in 4-12 weeks (BI-RADS category 3) following the second vaccine dose.
- If axillary adenopathy persists after short term follow up, then consider lymph node sampling to exclude breast and non-breast malignancy.
We reached out do Dan Karolyi, MD, PhD, who is Professor and Chair of the Department of Radiology at Carilion Clinic and VTCSOM for his insights. He provided some additional insights and cautions: “Our concerns are 1) Some patients are already delayed on getting their screening exam and this could further delay them and 2) If for whatever reason there is a delay in getting the second shot, they could get lost to follow-up.”
Dr. Karolyi also shared there was an article released recently by the major cancer centers regarding women with a history of breast cancer recommending that:
- The shot be given in the arm opposite from where the breast cancer was.
- That cancer patients delay all imaging for 4 to 6 weeks after the COVID vaccine.
From the World of Musculoskeletal Medicine
3) Joint Injection Tips
As primary care clinicians we are no strangers to musculoskeletal (MSK) complaints in our day to day practice. In fact, over 100 million MSK complaints were addressed in ambulatory and emergency room settings in 2015, with ~38% of these occurring at primary care offices.
While many common MSK diagnoses can be treated with conservative treatments such as rest, ice, oral NSAIDs, and physical therapy, almost 2/3 of primary care clinicians report using corticosteroid injections as part of their treatment plans. For a variety of conditions a trial of injections is a reasonable approach, and if done in the primary care office it can improve patient satisfaction and cut down on costly referrals.
The majority of primary care clinicians are well trained in performing common injections, but if pushed to discuss protocols with colleagues would likely realize quickly there is much variability in how joint injections are done across the country. The following list emphasizes the common areas of variability and tips on clinic standardization.
5 Essential Considerations for Corticosteroid Injections
1. Injection location
- Many common injections have multiple approaches if searched in the literature. Technically speaking, most do not have preferred or “Gold standard” approach as many factors weigh into this decision. Namely, physician comfort and patient considerations such as overlying skin changes or swelling, difficulty positioning patient, or general patient body habitus.
- For improved standardization it is recommended to have a known preferred method for each of the injections preformed in your clinic. This allows for staff and patients to have uniform expectations with subsequent injections.
- Clinicians are encouraged to know an alternative approach in case of patient needs, or to acknowledge when the clinic preferred method is unable to be performed and refer at that time.
- Procedure notes need to include consent, sterilization procedures, anatomic landmarks, injection approach, needle and injectant used, and any potential post-injection complications.
- Standardizing the approach for each injection in your clinic will allow for templated procedure notes with more detailed anatomic descriptions. Increased description of landmarks and direction of needle placement allows subsequent providers to better understand injection preformed.
- Post-injection instructions with possible reactions should be provided
3. Injectant choice
- A quick review of the literature will show a vast array of injectants and doses and is the cause of much variability among clinicians. Both the steroid and anesthetic type, as well as the ratio, needs to be thoughtfully considered for each injection.
- The most commonly used steroids in the US are Triamcinolone Acetonide and Methylprednisolone. Steroids with low solubility are thought to stay in the joint longer, leading to less systemic absorption and possibly longer relief for patients, but these can cause increased cutaneous reactions and post injection flares. Often the brand chosen comes down to availability and cost.
- Anesthetics are used for dilution of the steroid and thought to decrease the propensity of glucocorticoid atrophy and post injection flares. They also provide immediate anesthetic relief to improve patient satisfaction. It should be stressed that they can be harmful to chondrocytes at higher concentrations and amounts. Ropivacaine and Lidocaine 1% are thought to have the least effect.
4. Injectant amount
- Steroids should be diluted with at least an equal volume of anesthetic, but commonly is 2-4x the steroid volume.
- Steroid doses should vary with the structure injected. Dose should decrease along with the size of the targeted structure to avoid atrophy and to allow space to administer the volume without having to inject against pressure
- For triamcinolone acetate a good rule is never more than 40mg, large joints 40mg, medium joints and tendons 20mg, small joints/spaces 10mg
- It is recommended to have a standardized injectant “cheat sheet” in your clinic. Attached is an example used our clinic.
5. Frequency of injections
- As research on corticosteroid injections continues there is increasing evidence that serial injections have negative effects on the progression of cartilage damage in knee OA. Based on the current literature it is recommended to limit injections to every 3-4 months with no more than 3 injections in a year per joint.
- A further recommendation would be to monitor response and increasing frequency to determine need for further imaging, therapies, or referral.
Many thanks to Bri Beach, DO, one of our residency faculty members with sports medicine fellowship training, for taking the lead on these tips. She and I agreed that we could all use a refresher on this important topic, and she has taught me much about the importance of knowing anatomical landmarks well if I want to obtain optimal outcomes.
- McNabb, J. (2015). A practical guide to joint & soft tissue injections. Philadelphia: Wolters Kluwer.
- Foster, Z., Voss, T., Hatch, J., & Frimodig, A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15; 92(8):694-9. Link
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.