Abstract: BackgroundMusculoskeletal (MSK) pain is a frequent complaint in patients who present to the emergency department (ED) and these patients are often treated with corticosteroids. However, there is mixed and low-level evidence for use of steroids in treatment of MSK pain. The College of Urgent Care Medicine has emphasized steroid stewardship in response to the increasing use of short course steroids in the ED. Steroid stewardship is the systemic effort to prescribe corticosteroids in a rational, evidence-based manner and evaluate the risks associated with short-term use. Steroids with enhanced glucocorticoid selectivity are preferred due to their anti-inflammatory effects but the risks are not benign. Adverse effects such as hyperglycemia, insomnia, dyspepsia, and changes in mood and appetite can occur even with short-term use. Patients at the Ralph H. Johnson V.A. Medical Center (RHJVAMC) may be at higher risk of these adverse reactions based on age, comorbidities and drug-drug interactions with concomitant medications. Little evidence exists to guide use of steroids; therefore careful evaluation of risks and benefits is necessary. This project aims to evaluate the opportunity for steroid stewardship regarding the treatment of MSK pain.
MethodsThis retrospective analysis evaluated Veterans at the RHJVAMC that presented to the ED with a chief complaint of MSK pain based on selected ICD-10 codes from May 1st, 2024 to April 30th, 2025. The population was separated into two groups: patients prescribed steroids and patients that did not receive steroids. The electronic medical record (EMR) was utilized to collect data and determine eligibility for chart review. Patients were excluded if they received steroids for an indication other than MSK pain or were prescribed chronic steroids. The primary outcome was return visit rate within 30 days of index visit for the same MSK chief complaint. Steroid prescribing practices and ED interventions were also observed. The secondary outcome was the rate of steroid-related adverse drug reactions (ADRs) within 30 days of index visit in patients who received steroids in the ED or at ED discharge. A generalized estimating equations (GEE) analysis was performed to investigate associated factors that may impact return visit rates and is reported as adjusted odds ratios (aOR) and 95% confidence intervals (95% CI).
Results
Five hundred eighty-eight patients were included in the analysis; 283 patients received steroids and 305 patients did not receive steroids at the initial ED visit for MSK pain. The primary outcome of return visit for the same MSK pain complaint was significantly higher in patients that received steroids compared to the no steroid group (aOR 1.96, 95% CI 1.05-2.63; p = 0.003) within 30 days of initial ED visit. The GEE model confirmed the administration of steroids was independently associated with rate of return. The majority of patients received intramuscular (IM) dexamethasone in the ED (76.2%) and were discharged on prednisone with a mean 6.4 day (SD ± 3.8) duration of therapy. Pain consultations differed between groups (2.7% vs 0.7%, p=0.022), but were overall seldomly utilized in this patient population. Secondary outcomes data identified 8 patients that experienced steroid-related ADRs. Most of these patients received dexamethasone 10mg (IM) (75%) and all were discharged with multimodal pain control including steroid, NSAID, muscle relaxer, and/or topical pain relief.
Conclusion
Patients who received steroids in the emergency department for MSK pain were more likely to return for the same chief complaint within 30 days compared to patients who did not. ED interventions for MSK pain, like specialty pain or physical therapy consultations, were found to be under-utilized and warrant further investigation for impact on return rates. Few steroid-related ADRs were observed in this retrospective analysis.
