Rheumatoid arthritis (RA) is a chronic, inflammatory, often progressive condition that is driven by an autoimmune process.

The early diagnosis of this disease along with aggressive medical intervention can often lead to remission in many cases.

In addition to non-steroidal anti-inflammatory drugs (NSAIDS), low doses of glucocorticoids such as prednisone, methotrexate, and biologic interventions like etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade). There are also second generation biologic drugs. These include abatacept (Orencia) and rituximab (Rituxan).

Unfortunately, some patients will have their disease managed except for one, two, or perhaps three stubborn joints that remain inflamed.

For these patients, an injection of glucocorticoid better known as the cortisone shot" may be helpful for controlling this localized disease. Virtually any joint in the body can be injected with glucocorticoid. In addition, other areas such as bursae, tendon sheaths can also be injected with glucocorticoid. However, let's discuss some important issues having to do with swollen joints first.

When a patient with rheumatoid arthritis- or any arthritis for that matter- presents with a swollen, tender, painful joint, it is imperative that an arthrocentesis be performed. This procedure involves the insertion of a needle into a joint. An arthrocentesis serves two purposes.

The first is diagnostic. Regardless of the diagnosis a patient has, one cannot assume that the painful swollen joint is due to that disease only.

If there is fluid inside the joint, the retrieval and analysis of the fluid may show that another problem exists. For instance, a patient with a diagnosis of RA with a red tender swollen joint may have a septic arthritis- an infected joint. The only way to make this diagnosis is to get the fluid, examine it, and culture it. The treatment would involve antibiotic therapy and possible more drainage of the infected joint. Why is this important? Because septic arthritis is a potentially crippling and life threatening problem, particularly in patients with rheumatoid arthritis who may be on immunosuppressive therapies..

Another example is a crystal-induced form of arthritis. Gout and pseudogout can cause painful swollen inflamed joints in patients with rheumatoid arthritis. Examination of the fluid obtained from the joint will show crystals of either monosodium urate (gout) or calcium pyrophosphate (pseudogout). If the diagnosis is a crystal induced flare, the treatment would be aimed at this problem and the rheumatologist would be less inclined to push systemic therapies for the RA.

Obviously, the tender swollen joints could also be due purely to the RA. This would then indicate that perhaps a different direction in the RA therapy may be needed.

The second major purpose is therapeutic. Injection of glucorticoid after drawing off the fluid will help suppress inflammation and make the patient more comfortable.

Some key points need to be considered:

The procedure is a sterile procedure so certain precautions to maintain sterility should be followed.

The area to undergo needling" should be anesthetized first. Some people use ethyl chloride spray. At our center, we numb the area with lidocaine before entering the joint.

The initial entrance into the joint, after the area has been sterilized and anesthetized, should be done with a needle attached to an empty syringe so that if fluid is present, it can be drawn off.

The person doing the procedure should be extremely experienced. An inexperienced physician can not only make the procedure more painful than it should be but they may not perform the procedure correctly. A poorly done procedure may not get the fluid needed for diagnosis and the injection of glucocorticoid may not be given into the joint where it is needed. A poorly done procedure can be worse than no procedure.

Ultrasound guidance needs to be employed. If the needle tip is not in the right place, the glucorticoid will not be injected into the right area and the patient won't have a good outcome.

If there is fluid drawn off the joint, that syringe is removed with needle in place and the syringe containing the glucocorticoid is then attached to the needle and the glucocorticoid is administered. That way a patient only needs to get one needle, not two.

The same joint should not be injected more than three times per year.

As for areas, other than joints, the same precautions should apply. In addition, prior to injecting into soft tissue (muscle, tendon, bursa), the doctor should always draw back on the syringe first to make sure the needle is not inside a blood vessel. If the glucorticoid solution is injected directly into a vein, severe problems, including death can occur.

Cortisone shots should never be given through an area of skin that might be infected. Patients with severe diabetes may notice a spike in their blood sugar for two to three days after a cortisone shot.

Cortisone shots can cause a flare" in pain the night after the shot. A patient should rest the area, use ice, and be told about the possibility of a flare.