Corticosteroids: short-term gain for long-term pain?

Although the 1949 discovery of cortisone was a medical landmark, it is still unclear whether this widely used treatment benefi ts patients with tendon pain. In The Lancet today, Brooke Coombes and colleagues evaluate whether corticosteroid injection helps or harms patients with tendinopathies. This question is relevant not only for physicians, but also for other health professionals such as those physiotherapists whose extended scope of practice includes corticosteroid injection. Coombes and colleagues’ systematic review examines the outcome of patients with tendinopathy at 4 weeks, 6 months, and 12 months after corticosteroid injections. These important long-term outcomes have been largely overlooked in reports of the effi cacy and safety of corticosteroid injections. Coombes and colleagues show that tendons behave diff erently at various anatomical sites. Importantly, today’s review might discourage clinicians from using corticosteroids in patients who are seeking medium-term and long-term cures. For lateral elbow tendinopathy (tennis elbow), there was a 21% reduction in the relative risk of overall improvement 1 year after corticosteroid injection compared with patients allocated to wait and see (relative risk 0·79, 95% CI 0·69–0·90). When considered alongside the higher absolute risk of recurrence of 63%, this discovery is crucial because it alerts clinicians to the potential deleterious eff ect of corticosteroid injections that are unrelated to complications of the injection itself. Conventional dogma has been that as long as corticosteroid injection did not cause an acute compli cation (eg, subcutaneous atrophy, tendon rupture), it was not harmful. Thus clinicians and patients often considered injection to be worth a shot. For lateral elbow tendinopathy, Coombes and colleagues’ analysis implies studies. Such withdrawals seem unavoidable in longterm clinical trials. Fifth, patients in the trials were mostly men with cardiovascular risk (men only in two trials), thus, no conclusions can be made about women and patients with no cardiovascular risk. The mechanisms of colon carcinogenesis might diff er between cardiovascular and other patients—eg, because of increased tobacco consumption. Finally, after completion of the randomised periods of the trials, all patients were exposed to aspirin, which would have underestimated its benefi ts. No randomised trial is currently exploring the eff ect of aspirin on colorectal cancer. In a prospective cohort study of 1279 men and women, regular aspirin use after colorectal cancer diagnosis was associated with a reduced risk of cancer-specifi c and overall mortality, specifi cally in patients whose initial tumour over expressed COX-2. This interesting study could incite clinicians to turn to primary prevention of colorectal cancer by aspirin, at least in high risk-populations. Specifi c guidelines for aspirin chemoprevention would be the next logical step.