MLWhitworth, MD  
Depomedrol and Steroid Injection Controversies
Question:Aren’t steroids bad for the body producing osteoporosis, fluid retention, high blood
pressure, high blood sugar, adrenal gland suppression, and immune system depression?
Answer: Studies demonstrate the lack of development of osteoporosis even with large quantities of epidural
steroid injections up to 3,000 mg.  Typically 40-120mg are used for an injection.  There is a transient
increase in blood pressure and blood sugar for about a week.  This is usually only important for those with
pre-existing diabetes or hypertension.  In such cases, more frequent monitoring of blood sugar and blood
pressure may be required for the first week and occasionally a temporary adjustment in dosage of diabetic
medications and antihypertensive medications is needed.  Injections of steroids do suppress the adrenal
glands which require up to one month to begin to recover.  For that reason, it is prudent to avoid steroid
injections at intervals of less than one month.  There is some transient fluid retention with any steroid
injection or oral formulation.  Long term frequent administration of high dose steroids can cause significant
weight gain of up to 40 lbs in a year, therefore it is prudent to use the steroid injections sparingly.   The
immune system is only briefly compromised after epidural steroid injections.

Question: My orthopedic doctor gives me monthly injections into my shoulder and my family doctor
gives me injections every 6 weeks into my tailbone.  Are these steroids different than those used in facet
blocks and epidural steroid injections?
Answer: The body sees the sum total of all injectable and oral steroids therefore the cumulative effect of all
these injections can be significant.  Tell your pain physician about all other steroid injections having been
received over the past several months.  Because of the potential for the development of osteoporosis (not
from the epidural steroids) and severe high blood pressure and blood sugar when receiving steroids from
multiple doctors, it is wise to lower the dose of the epidural steroids administered or hold off on receiving
other sources of steroids for a period of time (at least 6 weeks) before any further epidural steroid
injections.  The exception is that steroid asthma inhalers may be taken without any effect on the body’s
systems since these are not absorbed into the body.

Question: In the past, I was always scheduled for a “series of three” epidural steroid injections.  
Why are they not given in this way any longer?
Answer: There is no scientific evidence that the “series of three” has any more beneficial effect than do
injections spread out over time.  The original descriptions in the literature used a “series of three” without
any justification.  Medicare eventually adopted this non-sense, believing it to be the standard of care, and
limited epidural steroid injections to 3 per year.  Fortunately, new guidelines being developed by Medicare
recognize steroid injections may need to be administered as often as every 2 months.  Only doctors trying to
make a fast buck without any shred of science still do a scheduled “series of three” epidural steroid
injections, often scheduling them dangerously close to one another (1-2 weeks) which does not permit the
adrenal glands to recover.  If a person is subsequently in an auto accident, develops shock from any cause,
etc., then the lack of adrenal function can be life threatening.  Other doctors who are ethical and use
evidence based medicine to guide them will re-assess the patient’s needs prior to going forward with each
injection.  Some patients derive much longer relief from epidural steroid injections (up to a year) and
therefore certainly do not need the series of three scheduled injections.

Question: I have been told depomedrol is made of brake fluid or antifreeze.  Isn’t that dangerous to
Answer: There are some websites which incorrectly claim that people being given Depomedrol are
receiving brake fluid or antifreeze. As a physician with a masters degree in chemistry I can attest that these
websites contain absolutely incorrect information. It may be the deluded individuals posting such are so
angry at their own misfortunes that they want to create havoc and destruction as a means of striking out
blindly at every facet of possible causes for their misfortune.  Antifreeze is ethylene glycol which is toxic to
humans and animals when injested.  But the polymer of ethylene glycol is not toxic at all and is widely used
throughout medicine in many drug preparations.  Just as styrene is very toxic to humans, polystyrene is not
toxic at all.  There are many more examples where the polymer of a toxic monomer is used in our everyday
lives without toxicity.  
Depomedrol contains polyethylene glycol. Just as does Tylenol, milk of magnesia, Apo®-Desipramine,
Bactroban, Wellbutrin SR, and a large number of other drugs such as the anti-constipation drug Miralax
(nearly 100% polyethylene glycol).  Some injectable drugs such as some insulin formulations and some
interferon injections contain polyethylene glycol.
BioSante Pharmaceuticals Reports Positive Results of Long Acting ... Nov 6, 2003
Scientists at BioSante's research center in Smyrna, Georgia, developed a formulation combining CAP,
polyethylene glycol (PEG, a polymer) and insulin. ... (Business Wire (press release))
PEG-INTRON, the only interferon product for hepatitis C approved for dosing according to body weight,
uses proprietary PEG technology developed by Enzon, Inc. (NASDAQ: ENZN) of Bridgewater, N.J. PEG-
INTRON, recombinant interferon alfa-2b linked to a 12,000 dalton polyethylene glycol (PEG) molecule, is
a once-weekly therapy that has been shown to exert both antiviral and immunomodulatory effects. Schering-
Plough holds an exclusive worldwide license to PEG-INTRON. REBETOL is an oral formulation of the
antiviral agent ribavirin, a synthetic nucleoside analog.
Professors reinvent blood Mar 7, 2004
Armstrong and Fisher employed polyethylene glycol (PEG), a simple polymer that can coat normal red
blood cells, to create the universal blood. ... (Daily Trojan Online -)

Many foods contain polyethylene glycol. As one can see in the following analysis, there is NO polyethylene
glycol in the most commonly used brake fluid:
Valvoline DOT 3 Brake Fluid
There are websites making these absurd claims in order to generate interest in suing the manufacturers of
Depomedrol.  Such websites are often run by lawyers or by patients with pre-existing chronic pain who
believe the Depomedrol injections created their pain.  (Yeah, it is mind boggling how even though the
timing cannot possibly implicate Depomedrol injections, in their mind they deserve “compensation” for
their pre-existing chronic pain.  

Question: I have heard Depomedrol and all other steroid preparations do not have FDA approval to
be injected into the epidural space.  Is this true?
Answer: This is correct.  The manufacturers never submitted the drugs to the FDA for use in the epidural
space.  The process of approval costs up to $60,000,000 and since the drugs have been used safely and
effectively for over 40 years in this manner, it is not necessary to obtain FDA approval.  The FDA gives
initial approval for a drug for a specific use, then the uses are expanded by physicians who find other
benefits of the drugs.  FDA approval is neither necessary for a specific use, nor is commonly obtained.  
There are many other “off label” uses of drugs in pain management such as Neurontin (not approved for
treatment of pain), Elavil/Trazadone (not approved for use to augment sleep or reduce chronic pain), etc.
etc.  There are over 700 published papers on epidural steroids with such a long track record of use that it is
unlikely FDA approval for epidural use of these drugs will ever be submitted.  The FDA encourages off-
label use of drugs.

Question: There are a few reports of paralysis after injections of these drugs, especially when given
transforaminal (along the nerve root).  Is that true?
Answer: This is true.  Both with lumbar injections and with cervical injections, long standing paralysis has
occurred.  It is believed this is due to the injection of the drug directly into a blood vessel, and over the past
couple of years, increasing safety measures have been adopted across the country to help prevent these
disasters.  These include performing a neurogram (injection of contrast dye prior to the steroid), use of real
time injections under fluoroscopy to look for blood vessels, and where available, the incorporation of
digital subtraction (an advanced radiology technique).  Given the millions of epidural steroid injections per
year and the extremely few cases of injury, overall statistically the injection is very very safe.