Olecranon Bursitis

The olecranon bursa allows the skin to glide freely over the olecranon process. Given its superficial location, however, it is susceptible to inflammation from acute or repetitive trauma.

Acute injuries can be secondary to any repetitive trauma (eg, the constant rubbing of an elbow against the table as a person writes) or secondary to a sports-related activity that includes direct or repetitive trauma to the posterior elbow (eg, landing on the olecranon process during a fall onto a hard floor or an artificial-turf playing field).

Septic bursitis, a less common cause of olecranon bursa inflammation, can result from an abrasion or laceration of the affected site or by way of seeding from hematogenous spread via bacteremia. Inflammation can also be caused by a systemic inflammatory process (eg, rheumatoid arthritis) or a crystal-deposition disease (eg, gout or pseudogout). Additionally, septic bursitis may develop as a secondary complication of aseptic olecranon bursitis.[1] Risks factors for the development of non-traumatic olecranon bursitis include diabetes mellitus, uremia, a history of intravenous drug abuse, alcohol abuse, or long-term use of steroids.[13, 14, 15, 16, 17, 18]  Larsen et al reported a case of bacillus Calmette-Guérin (BCG) olecranon bursitis that developed from disseminated BCG infection, the result of BCG treatment for superficial bladder cancer.[19]

In patients on long-term hemodialysis treatment, uremia or a mechanical insult (such as resting the posterior elbow during hemodialysis treatment) is thought possibly to cause bursitis.[20] Inflammation of the bursa can also be an adverse effect of the drug sunitinib, which is used to treat patients with renal cell carcinoma.[21]

A retrospective study by Schermann et al of olecranon bursitis in the Israel Defense Forces found the condition to be more prevalent in combat units than in noncombat units, with most of the diagnoses being made during summer and autumn, when training is particularly intensive. The investigators stated that the relatively high number of olecranon bursitis cases diagnosed during those times of the year is probably related to outdoor training that requires crawling and suggested that the use of protective gear could alleviate the problem.[22]

Most cases of aseptic olecranon bursitis respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with additional treatment. Some patients may experience recurrence, in which even relatively minor trauma causes a significant effusion to reappear.

Complications

Complications of olecranon bursitis include progressive or persistent pain potentially associated with functional impairment of the affected upper extremity. Potential complications of aspiration/injection include the following:

• Bleeding

• Bruising

• Allergic reaction to corticosteroids (if utilized)

• Swelling - This may recur, particularly if the patient does not maintain adequate pressure or icing at the site or if an infection was present at the time of the initial aspiration

• Infection - The clinician should use appropriate aseptic techniques to minimize the chance of iatrogenic infection

• Persistent drainage through the injection tract

• Ulnar nerve injury - This theoretically may occur if a medial approach is used for the aspiration/injection

• Transient elevation of blood glucose levels (if corticosteroids are utilized)

• Cardiac arrhythmia - This potentially can result from intravascular injection, due to the local anesthetic component

• Peripheral nerve dysfunction - This is possible if the injection is administered near or within a major nerve

• Compromised wound healing

• Gastric, hepatic, and renal adverse effects from NSAIDs and narcotic analgesics

The patient should be educated regarding olecranon bursitis’s diagnosis, causative factors, and treatment plan. The most important aspect of patient education is ensuring that the patient understands the importance of and knows to immediately report any signs or symptoms of persistent drainage or infection, particularly if a corticosteroid injection has been given. Diabetic patients should be told that they may experience a transient elevation of their blood glucose levels.

Patients should be informed that a corticosteroid usually does not begin to provide symptomatic improvement until a few days after the injection. Patients should also understand that they may experience a mild, transient increase in symptoms during the window of time when the local anesthetic has worn off but the steroids have not begun to take therapeutic effect. For patient education information, see the Arthritis Center, as well as Bursitis.

Patient history may include the following findings:

• Focal swelling at the posterior elbow, usually noticed by the patient
• If the condition is painful, it often is exacerbated by pressure, such as when the patient leans on the elbow, or can be associated with prolonged elbow flexion over 90°; the patient may report pain at the affected site, although sometimes the swelling is painless, especially in cases of noninflammatory, aseptic bursitis
• If the condition is painful, there will likely be an associated range-of-motion (ROM) loss in the elbow, especially in the presence of acute trauma or infection
• The patient may report a history of isolated trauma (eg, contusion) or repetitive microtrauma (such as constant rubbing of the elbow against a table while writing)
• Episodes of acute swelling are likely due to trauma or infectious/inflammatory etiologies, while episodes of gradual onset are likely secondary to chronic irritation

Classically, olecranon bursitis presents with a well-demarcated, fluctuant posterior elbow swelling that appears as a “goose egg” over the olecranon process (see the image below).

Olecranon bursitis seen with the elbow extended. Focal swelling at the olecranon is more visible with the elbow extended than in the flexed position. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

Other findings in olecranon bursitis include the following:

• Vital signs may reveal fever, but generally only with cases of advanced/systemic infection
• The area around the olecranon may be warm and erythematous, particularly with infectious etiologies
• Skin inspection may reveal abrasion or contusion if trauma recently occurred
• Upon inspection of the elbow, rheumatoid nodules may be found in patients with rheumatoid arthritis (see the image below); firm “bumps” or “lumps” due to residual scar tissue may be felt as swelling recedes, especially with even mild trauma to the elbow; these nodules may persist or resolve spontaneously
• In patients with systemic inflammatory processes (eg, rheumatoid arthritis) or a crystal deposition disease (eg, gout, pseudogout), evidence of focal inflammation at other sites or inflammation extending distally in the forearm (if associated cellulitis is present) may be revealed
• The affected site may be tender to palpation; however, pain is variable. Severe pain is often due to a traumatic or infectious cause; in painful cases of olecranon bursitis, pressure on the tip of the elbow may interfere with sleep
• Elbow ROM usually is normal, but occasionally the end range of elbow flexion is slightly limited because of pain or, in chronic cases, due to bursal thickening; this decreased ROM may interfere with performance of basic activities of daily living, such as dressing, bathing, and grooming
• Sensation should not be impaired, distal pulses should be intact, and other joints should not be affected
• The inflamed bursa should be measured and demarcated on subsequent encounters in order to assess progress/resolution, or lack thereof, based upon the treatment modality selected
• Rheumatoid arthritis. Rheumatoid nodules at the elbow. Photograph by David Effron MD, FACEP

Usually, laboratory studies are necessary only if the clinician suspects that an underlying condition is present. If an infection is suspected, the olecranon bursa should be aspirated as outlined below. Lab work, including a complete blood count (CBC) with differential, serum C-reactive protein, erythrocyte sedimentation rate, and glucose, should be obtained. The literature has indicated that a ratio of bursal fluid glucose concentration to serum glucose concentration of less than 50% is diagnostic of a septic bursitis; however, some studies refute this finding, stating that this comparison has a false-negative rate of 9%.[23] If there is concern for rheumatoid arthritis or gout, tests should include a rheumatoid factor and uric acid level, respectively.

If infection is suspected (due to the presence of fever, erythema, previous puncture wounds, or cellulitis), the olecranon bursa should be aspirated and the fluid sent for culture, a cell count (WBCs, RBCs), and immediate Gram staining for bacteria. If the Gram stain is positive for bacteria, antibiotics should be started immediately and no corticosteroids should be injected into the bursa.

However, even if the Gram stain is negative or initially unavailable, withholding corticosteroid injection and starting antibiotics may seem indicated based on the mechanism of injury (eg, abrasion or puncture), physical examination findings suggestive of infection (eg, fever, significant local erythema and warmth), or the overall appearance of the aspirate (eg, turbid, purulent).

WBC count

The leukocyte count can help to determine whether the fluid is infectious or merely inflammatory.[24] Within synovial aspirates, WBC counts are assessed as follows:

• Less than 200/µL - Normal

• 200-2000/µL - Noninflammatory

• 2000-100,000/µL - Indicative of an inflammatory etiology

• >100,000/µL - Indicative of a septic etiology

Bacterial culture

Bacterial culture and sensitivity testing of the aspirate can be performed to ensure that the relevant bacteria are sensitive to the chosen antibiotic. These results can guide the modification of antibiotics in cases of bacterial infection. The most common organism cultured is the gram-positive coccus penicillinase-producing Staphylococcus aureus.[23, 25]

Other findings

After an acute injury, blood may be found within the aspirate, indicating a hemorrhagic bursitis (see the image below).

Aspiration of a hemorrhagic effusion in a patient with olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

Analysis for crystals may reveal monosodium urate crystals in patients with gout, calcium pyrophosphate crystals in pseudogout, or hydroxyapatite crystals (see the image below).

Gout. Polarizing microscopy revealing needles of urate.

Radiography

Plain film radiographs of the elbow should be performed to assess for a possible olecranon fracture if significant trauma occurred or if an avulsed osteophyte is present at the triceps insertion into the olecranon, which is fairly common. (See the image below.)

Olecranon fracture.

Gout. Radiograph of erosions with overhanging edges.

Ultrasonography

The use of ultrasonography has been shown to be extremely effective in the diagnosis of olecranon bursitis and other soft-tissue lesions in the olecranon area by rapidly demonstrating the presence of effusions, synovial proliferation, loose bodies, increased blood flow consistent with inflammation, tendonitis with calcifications, and other indications of bursitis.[8]

Magnetic resonance imaging

In atypical cases, an MRI study may be indicated to help exclude concomitant pathology, such as a stress fracture, triceps tendinopathy versus tear, or the rare case of osteomyelitis/abscess or tumor, especially if there is a long history of septic bursitis. This form of imaging is also helpful in the evaluation of an unusual mass seen on plain radiographs.[9]

The olecranon bursa can be aspirated using a long 18-gauge needle that is inserted after sterile skin preparation, using a circular motion with an antibacterial solution (after determining no applicable allergies exist) and appropriate local infiltration with a suitable agent, such as 1% lidocaine, using sterile technique to avoid secondary infection and a 27- to 30-gauge needle to make a skin wheal over the lateral bursa. The 18-gauge needle is attached to a 10-mL syringe and inserted into the dependent area of the bursa through a posterolateral approach, via an oblique needle angle or zigzag approach.[26]

As opposed to a direct, perpendicular approach that is used for most joint aspirations, this technique creates a longer needle tract through the skin and subcutaneous layers, thus minimizing the risk of fistula formation. The medial approach to the olecranon bursa should be avoided, since a misdirected needle could damage the ulnar nerve. Aspiration of bursal contents is continued until the bursal site is flat. The needle is then withdrawn and the wound dressed with adhesive sterile bandage and the elbow wrapped with a compressive dressing. Active elbow range of motion should be restricted for about 2 days post injection. (See the images below.)[13, 14, 15]

Olecranon bursogram. This image shows a needle injecting contrast material into the olecranon bursa, under fluoroscopic guidance. Although olecranon bursa aspiration/injection usually does not require fluoroscopy or contrast, employing fluoroscopy here has demonstrated the outline of the involved bursa. Image ©2005, by Patrick M. Foye, MD, UMDNJ: New Jersey Medical School.

Needle aspiration in olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

After fluid is removed from the olecranon bursa, an elastic, tubular compressive sleeve can be used to minimize reaccumulation of the fluid. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

If cloudy fluid is aspirated, it should be sent for immediate Gram stain, leukocyte count, culture, and antibiotic sensitivity testing. No corticosteroids should be given until these tests prove negative. Aspiration can also be therapeutic, as it relieves the swelling. If cultures of aspirated fluid are negative and fluid recurs, the bursal aspiration can be repeated, and, if sterile on culture, corticosteroids can be considered.

If the clinician is confident that no infection is present, corticosteroid injection can be considered (for instance, immediately after aspiration of the fluid).[27]

In the absence of a traumatic etiology, consideration should be given to analyzing the aspirated fluid for infection and crystals.

When aspiration/injection is performed, aseptic techniques should be used to minimize the chance of causing iatrogenic infection. Septic olecranon bursitis due to Mycobacterium smegmatis has been reported after intrabursal steroid injection.[28]

The patient’s history and physical examination should be considered when administering treatment for olecranon bursitis, as in the following cases:

• Pregnant patient - Aspiration of the bursa and corticosteroid injection can be performed during pregnancy; oral nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided

• Elderly patient with history of side effects from NSAIDs - It is necessary to be cautious when using NSAIDs in elderly patients; cyclo-oxygenase-2 (COX-2) inhibitors may be indicated

• Patient with diabetes - Some patients with diabetes may experience a transient elevation in blood glucose levels after corticosteroid injections

In general, physical and occupational therapy are not needed in the treatment of olecranon bursitis. In some cases of aseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed recovery time. Additionally, in cases of aseptic bursitis without concern for secondary trauma such as an acute fracture, therapeutic manipulation should be considered, since soft tissue and joint mobilization can assist in edema control. Physicians should, however, have a low threshold for consideration of an infectious etiology in the patient’s bursitis, as at least 20% of cases of acute olecranon bursitis have a primary or secondary septic cause.[1]

Usually, no surgical intervention is required in cases of olecranon bursitis.[11] If the patient's condition becomes severe and does not respond to conservative treatment, however, bursectomy may be indicated. Based on a literature review, Baumbach et al suggested that even in cases of septic olecranon bursitis, the evidence supports the initial use of conservative treatment rather than immediate bursectomy. They state that only patients with severe, refractory, chronic/recurrent olecranon bursitis should be treated via incision, drainage, or bursectomy.[29, 25]

If surgical intervention is required in olecranon bursitis, endoscopic olecranon bursal excision is an effective alternative to open incision in either aseptic or septic cases. Endoscopic outcomes are excellent and can minimize wound-healing problems.[12]

A study by Ogilvie-Harris and Gilbart demonstrated that endoscopic bursal resection relieves pain symptoms and typically gives satisfactory results in patients with chronic olecranon bursitis.[30, 31]

A study by Meric et al also reported good results from endoscopic bursectomy, for either prepatellar or olecranon bursitis. The 49 patients in the study, including 30 with olecranon bursitis and 19 with prepatellar bursitis, were treated endoscopically (25 patients) or with open bursectomy (24 patients). At follow-up, the endoscopic group scored 8.5 on a patient satisfaction questionnaire, compared with 5.3 by the open surgery group.[32]

A novel approach by Kettering et al using an olecranon bursectomy with deepithelialized advancement flap reconstruction was introduced with successful results; however, the investigators reported on only two patients.[33]

The underlying etiology of a patient’s olecranon bursitis must be considered when pursuing surgical interventions. For example, Stewart et al found that only 40% of individuals (2 of 5) with rheumatoid arthritis who underwent surgery experienced complete and long-term relief, compared with 94% of patients (15 of 16) without rheumatoid arthritis.[34]

A study by Uçkay et al suggested that for adult patients with moderate to severe septic olecranon bursitis, the rate of wound dehiscence is lower with one-stage bursectomy than with a two-stage approach to the procedure. The investigators found that 1 out of 66 patients in the one-stage group experienced wound dehiscence, compared with 9 out of 64 in the two-stage group.[35]

Prevention

A compressive elbow sleeve (eg, a neoprene or elastic sleeve) may help to prevent the bursal fluid from reaccumulating after aspiration, but the application of excessive pressure over the elbow should be avoided.

Avoiding further trauma to the olecranon bursa is the key to recovery and prevention of recurrence. Consider use of elbow pads to cushion the elbow.

For cases of olecranon bursitis in which there is repeated recurrence, consider use of a posterior plaster splint to limit elbow motion for 1-2 weeks following aspiration. For severely recalcitrant cases, consider referral to an orthopedic surgeon for possible bursal excision.

Monitoring

The patient should return for reevaluation within approximately 2-7 days after the initial encounter, depending upon the severity of presentation. At that time, an assessment should be made regarding the reaccumulation of fluid, persistent drainage, and signs of infection. These assessments should be derived by clearly demarcating the bursa distention at the initial encounter; in that way, an assessment can be made in subsequent encounters regarding the progression/resolution, or lack thereof, of the patient’s olecranon bursitis.

Activity

The athlete with olecranon bursitis may be expected to return to play without restrictions after he/she has demonstrated resolution of symptoms, is devoid of any positive physical examination findings (eg, swelling, tenderness to palpation), and has shown adequate performance in sports-specific practice drills without recurrence of symptoms.

As previously mentioned, in the absence of infection most cases of olecranon bursitis respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with additional treatment.

A retrospective study by Weinstein and colleagues showed that in 47 patients with traumatic olecranon bursitis, almost all cases resolved via aspiration, with or without intrabursal glucocorticoid injection.[36] In the 25 patients who did receive glucocorticoid injection (20 mg of triamcinolone) in addition to bursal aspiration, the bursitis resolved much more rapidly than it did in the other patients, usually within 1 week. However, there seemed to be an association between the glucocorticoid injections and the development of complications, such as infection and skin atrophy.

A study by Kim et al reported that in the treatment of aseptic olecranon bursitis, no difference in efficacy was found between the use of aspiration, the use of aspiration combined with steroid injections, and the use of compression bandaging combined with nonsteroidal anti-inflammatory drugs (NSAIDs), at 4-week follow-up. The investigators cautioned, however, that the study, which involved 83 patients, was powered to identify no less than a 30% difference between the three treatments, which means that if a smaller difference in efficacy existed, it may not have been detected.[37]

Oral NSAIDs can help to reduce the pain and inflammation of olecranon bursitis, but these products probably should be avoided if joint aspiration reveals a hemorrhagic bursitis. Injectable corticosteroid can be beneficial in cases in which the history, physical examination, and joint aspiration do not raise a significant suspicion of infection.[10]

Focal corticosteroid injection may be an option, but only if the clinician is confident that no local infection is present.

The decision as to whether the patient should be treated with empiric antibiotics depends on the perceived likelihood of infection, as indicated by patient history, physical examination, and analysis of the bursal aspirate.

In a study of 343 episodes of septic bursitis, including 237 episodes of olecranon bursitis and 106 of patellar bursitis, Perez et al found that 7 days or less of antibiotic treatment was as effective as antibiotic therapy lasting from 8 days to more than 2 weeks. The investigators also found that short-course antibiotic therapy was not associated with a recurrence of bursitis.[38]

A retrospective study by Deal et al suggested that patients with uncomplicated septic olecranon bursitis can effectively be treated with empiric antibiotic therapy without aspiration. Among 11 patients who underwent traditional bursal aspiration, only one culture resulted in an alteration of antibiotic management. Moreover, despite the information derived from the cultures, five patients still had incomplete resolution with antibiotic therapy, requiring a second course of antibiotics, while eight patients subsequently needed a bursectomy. Among the 19 patients who underwent empiric antibiotic therapy without aspiration, only three individuals needed a second antibiotic course. Symptom recurrence occurred in one of the empiric therapy patients 2 months after the bursitis had resolved with a single antibiotic course, with a second course resolving the problem. None of the empiric therapy patients required bursectomy.[39]

Injection technique

The injection should be on the lateral side of the elbow, so as to avoid the ulnar nerve. The target injection site is the soft-tissue center of the triangle formed by the lateral olecranon, the head of the radius, and the lateral epicondyle. As with most injections, the physician should first aspirate to ensure that the needle is not in a blood vessel and then inject using a slow, but consistent, pressure.[10, 36]

Corticosteroids should never be injected into a site that appears to be infected or through skin that appears to be infected.

As previously mentioned, although physical and occupational therapy are generally not needed for olecranon bursitis, in some aseptic cases the physician may recommend a course of physical or occupational therapy to speed recovery time.

Individuals who exhibit olecranon bursitis are advised to apply the RICE (rest, ice, compression, elevation) method of treatment. Icing of the posterior elbow for 15-20 minutes at a time, several times daily, is recommended during the acute period (2-5 days).

Physical therapy modalities (eg, phonophoresis, electrical stimulation) also may be helpful in further reducing pain and inflammation, although these modalities are not necessary for most patients.[40]

The therapist can also complete patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. For the patient who undergoes bursal excision (bursectomy), physical therapy may be recommended postoperatively for regaining or maintaining the elbow's ROM and strength.

Consultation with a physiatrist (physical medicine and rehabilitation physician) or with another qualified musculoskeletal specialist may be considered by physicians without the training, comfort, or procedural office supplies necessary for joint aspiration.

Consultation with a rheumatologist may be helpful if the clinical findings are consistent with inflammatory arthropathy.

Consultation with an orthopedic surgeon is required if a fracture is present, if the patient has a very severe case of recalcitrant bursitis that requires excision (bursectomy), or if incision and drainage are required for septic bursitis.

Medications are used in cases of olecranon bursitis primarily to decrease pain and inflammation. Thus, the most commonly used medications are oral NSAIDs and focal corticosteroid injection, in conjunction with the rest of the rehabilitation plan.[10]

As previously stated, however, oral NSAIDs probably should be avoided if joint aspiration reveals a hemorrhagic bursitis. Injectable corticosteroid can be beneficial in cases in which the history, physical examination, and joint aspiration do not raise a significant suspicion for infection.

Empiric antibiotic selection is based on the suspected source of the microorganisms (local invasion by skin flora via puncture or abrasion, or hematogenous spread from a primary infection at another body site). Initial antibiotic selection is also directed by the results of the Gram stain of the aspirate.

Antibiotic treatment may start with a broad-spectrum antibiotic; then, when the culture and sensitivity test results are available, the antibiotic regimen may be modified as appropriate. Unless the patient is immunocompromised, targeted oral antibiotics should be the preferable initial treatment approach. If the infection does not respond to oral antibiotics or is discovered later in its evolution, intravenous antibiotics with or without surgical irrigation and débridement is indicated.

Class Summary

NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used. The choice of an agent is largely based on its side-effect profile, as well as on convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects), patient preferences, and cost.

Although increased treatment cost can be a negative factor, the incidence of costly and potentially fatal gastrointestinal (GI) bleeds is clearly less with cyclo-oxygenase-2 (COX-2) inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance in cases of GI bleeds will further define the populations that will find COX-2 inhibitors to be the most beneficial.

Ibuprofen (Motrin, Advil, Addaprin, Caldolor)

Ibuprofen is the drug of choice for mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available, either with or without a prescription.

Celecoxib (Celebrex)

Celecoxib inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, the COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.

Naproxen (Anaprox, Naprelan, Naprosyn)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase (COX), which is responsible for prostaglandin synthesis.

Ketoprofen

Ketoprofen is used for the relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with small body size, elderly patients, and persons with renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Class Summary

In contrast to the widespread, systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. A variety of corticosteroid preparations are available for injection. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Various local anesthetic agents also are available.

Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, A-Methapred)

Corticosteroids, such as methylprednisolone, are commonly used for local injections of bursae or joints to provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.

Methylprednisolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Dexamethasone (Baycadron)

Dexamethasone may reduce steroid hormone production. It decreases immune reactions. Dexamethasone provides a local anti-inflammatory effect while minimizing some of the gastrointestinal and other risks associated with systemic medications.