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Have had lifting injury. Had GI bleeding after taking toralol IM. What are the risks?

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General & Family Physician
Practicing since : 1986
Answered : 212 Questions
A patient has had a 3-week exacerbation of lbp from a lifting injury 1 year ago, and an ESI has been scheduled for moderate to severe foraminal narrowing at L4-5. I am concerned about the use of steroids, as he was admitted to the hospital last year for a GI bleed after having only one 30mg dose of toralol IM (never any PO NSAIDS). I realize the incidence of GI bleed is greater with NSAID than steroid, however, I am curious as to whether this patient is at greater risk now of having a serious adverse event.
Tue, 18 Dec 2012 in Bones, Muscles and Joints
Answered by Dr. Stephen Christensen 3 hours later
Systemic side effects from epidural steroid injections are relatively rare, particularly when only a single injection is administered. However, multiple procedures increase risk, and the elderly are also at higher risk for adverse events: gastric ulcerations and bleeding, transient hyperglycemia, hypertension, hypokalemia and susceptibility to infection. Therefore, physicians need to remain vigilant for unexpected complications in older individuals and those undergoing multiple ESIs. (This is especially true for the gentleman you've described here, who has already shown a tendency to bleed.)
It would be wise to be proactive in this case: a proton pump inhibitor (Prilosec, Prevacid, etc.) and/or H2 blocker (Tagamet, Zantac, Axid, etc.) prior to the ESI -- and perhaps for several weeks thereafter -- might be worthwhile. This man might also benefit from taking sucralfate. Stool hemoccults before and periodically after the procedure would forewarn of trouble and help head it off, too.
At least half of people receiving ESIs report significant pain relief after the procedure, so it's always worth considering this modality before proceeding with surgery. As always, though, the benefits must be weighed against the risks, and doctors should do everything within reason to ameliorate the obvious risks.
I hope that answers your question. I'll be available if you have additional concerns.
I hope things go well for this patient!
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