44 case reports, 37 prospective studies and 6 retrospective studies reporting on the adverse events of extra-articular local corticosteroid injections. Friedman SJ, Butler DF, Pittelkow MR: Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy. If you have osteoarthritis of the knee or hip, weight loss and beginning a physician-approved exercise routine may help improve function and put less stress on the joint. 10.1016/j.bjps.2008.11.059. Increased pain or steroid flare after injection was reported in 19 studies. Lidocaine has an average half-life of 1.5 hours to 2 hours, with an estimated duration of action of 0.5 hours to 3 hours.35 The bupivacaine has an average half-life of 2.7 hours, and an estimated duration of action of 2 hours to 8 hours.36. Another common side effect is aggravation of the inflammation that the shot was intended to treat. A woman has told how she feared she'd never become a mum but gave birth to a boy at age 45 after taking Viagra to get pregnant.. Carin Rockind, 48, welcomed a "miracle" baby after trying to have a . The mean age was 60.9 years (range 30 years to 88 years). Google Scholar. Learn more: How injectable OA treatments work , The side effects of cortisone shots occur right away or within 48 hours of receiving the shot. This management approach resulted in 70% of patients being successfully discharged, with a mean period of no further re-referral of approximately 2 years. 10.1053/j.jfas.2005.07.020. Talk to you doctor about a brace for your knee or. 2004, 25 (2): 48-52. 10.2106/JBJS.G.00230. This is the first line of treatment for cortisone flares. There are no previous methodological reports on post corticosteroid shoulder injection pain in the literature, and all the quoted figures are anecdotal. 10.1097/01.jsm.0000179233.17885.18. Responsiveness of the numeric pain rating scale in patients with low back pain. 2005, 15 (3): 119-124. In addition, in table 1 we reported the terminology as described in the individual articles, because it was not always clear which classification system they used. The shot should not affect fertility, pregnancy, or breast-feeding. The secondary outcome was determined at 6 months as successful discharge or progression onto surgery. Br J Sports Med. Topical corticosteroids are classified by strength and the risk of. 10.1016/S0140-6736(02)07811-X. 10.1097/00000372-199808000-00010. 10.1111/j.1742-1241.2006.01140.x. We note, from our results, that patients who developed flare had an initial lower VAS score (mean of 5.17) in comparison to patients who did not develop flare (VAS mean of 6.9). https://doi.org/10.1186/1471-2474-11-206, DOI: https://doi.org/10.1186/1471-2474-11-206. All rights reserved. After a cortisone shot, you should plan to avoid using the affected joint for the next two days. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N: Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. McIntosh HM, Woolacott NF, Bagnall AM: Assessing harmful effects in systematic reviews. J Neurol. We only report here on adverse events of injections that we know for certain were applied extra-articularly. 2009, 54 (1): 4-6. corticosteroids injections; physiotherapy; post injection pain; shoulder injections; shoulder pain; surgery. 1998, 57 (11): 700-10.1136/ard.57.11.700. See this image and copyright information in PMC. They include the high blood pressure drug losartan (Cozaar), the erectile dysfunction medicine sildenafil (Viagra, Revatio), the antidepressant fluoxetine (Prozac) and a class of medicines called prostaglandins. Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D: Injection of Dexamethasone Versus Placebo for Lateral Elbow Pain: A Prospective, Double-Blind, Randomized Clinical Trial. 10.1093/rheumatology/39.8.923. J Bone Joint Surg Am. 2005, 72 (1): 66-68. This page contains specific information for Viagra, not Revatio. A skin defect was observed after two injections of triamcinolone injected into a hypertrophic scar [28]. Brinks, A., Koes, B.W., Volkers, A.C. et al. As well as intense pain, people may have a buildup of fluid around the affected joint. 121. The newer, more synthetic, steroid anti-inflammatory medications are in our system for a much shorter period of time. Report of two cases and review of the literature. Bookshelf Am J Sports Med. Within a few days of receiving your cortisone injection, the pain from the flare should go away and you should feel relief. Joint Bone Spine. Cookies policy. Lancet. However, we failed to find all the relevant articles with the search strategy advised by the Cochrane Collaboration and had to expand the search strategy. 2004, 4: 19-10.1186/1471-2288-4-19. Inclusion in an NLM database does not imply endorsement of, or agreement with, Can kinesiology tape help knee arthritis? Those into the acromioclavicular (AC) joint were conducted via a direct anterosuperior approach, using a 23-G needle to account for the size of the joint gap. The injection needle was changed between drawing the medications and injecting them into the shoulder. Stopping the medication may be enough to improve or reverse the psoriasis flare. Payne JM, Brault JS: Digital ischemia after carpal tunnel injection: a case report. Learn about proteolytic enzymes for arthritis. Word DOC displaying search strategy in Pubmed and Embase. A depot preparation of 40mg of methylprednisolone (Depo-Medrone) was used in all patients, apart from those injected into the glenohumeral joint, where a double dose was used. Approximately half of this group was symptomatic for only the day of the injection, and the other half went on to be symptomatic for a mean of 3.8 days. Lievense A, Bierma-Zeinstra S, Schouten B, Bohnen A, Verhaar J, Koes B: Prognosis of trochanteric pain in primary care. Edwards IR, Aronson JK: Adverse drug reactions: definitions, diagnosis, and management. Results: Inflammation appeared spontaneously, usually 4-5 months after the last injection, but in 1 patient, almost 14 months later. Once you have a cortisone injection, your joint inflammation symptoms, including pain, should improve for the next two to three months. 10.1016/S0300-2977(99)00085-6. Dark orange coloured columns represent those who did not develop post injection pain/flare. See additional information. Although the adverse events reported in our review are 'miscellaneous' ones, we think that these types of adverse events (occurring after a regular dose of extra-articular corticosteroid injections) can be divided in systemic adverse events and local adverse events. In 2006 Dutch pharmacists delivered 208,380 prescriptions of injectable triamcinalone, representing 2,867,000 of the 86,250,000 total prescribed medication for the musculoskeletal system (3.3%) [5] it is however not known how many of the injectable corticosteroids are given intra- or extra-articular. Gottlieb NL, Riskin WG: Complications of local corticosteroid injections. Nine patients (7.7%) experienced severe flare (4-point increase in pain score). While there are some side effects of this treatment, cortisone shots are still one of the most effective solutions for the millions of people living with painful osteoarthritis. 2005, 15 (5): 370-375. Would you like email updates of new search results? One of these studies reported a complication after a ten-fold higher dose was accidentally given [16], and the other reported a case of a necrotizing fasciitis after a corticosteroid injection in the trochanteric bursa - which proved to be a lethal complication [17]. 'Side effect' was defined by any unintended effect, adverse or beneficial, of a drug that occurs at doses normally used for treatment, and 'complications' as an adverse events or effects following surgical and other invasive interventions. Injectable corticosteroids are nowadays registered for local treatment of (rheumatic) arthritis, synovitis, bursitis, epicondylitis, tendonitis, neuromas, ganglion cysts, entrapment syndromes, fasciitis and back pain [3, 4]. What you eat affects the progression and symptoms of osteoarthritis. This demonstrates as well that the technique is effective in producing the desirable effect in line with the recent Cochrane review suggesting that there is no added benefit from image guided injections.21. BMC Musculoskelet Disord 11, 206 (2010). HHS Vulnerability Disclosure, Help The data received from 'Lareb' were also analysed separately. (n.d.). Injection flare is a common side effect after a steroid injection Flares are caused by the corticosteroid medication used to treat common joint and tendon pathologies in the lower extremity Reddy PD, Zelicof SB, Ruotolo C, Holder J: Interdigital neuroma. In 1954 the first report on the effects of corticosteroids on healthy tissues appeared [1]. In a retrospective cohort study (on the five-year prognosis of trochanteric syndrome) 37% of the 164 cases were injected with corticosteroids [6]. A doctor will decide what steroid mixture and what dose to give in a cortisone injection, based on the condition and symptoms. In addition to pain, side effects can include: People should contact their doctor if they have any concerns about side effects they are experiencing. Graph describing the number of patients who had soft tissue injections and those who had intra-articular injections. Int J Clin Pract. Evans AV, McGibbon DH: Symmetrical hypopigmentation following triamcinolone injection for de Quervain's tenosynovitis. Depending on the place where the injection is administered, adverse events can manifest, for example, injections for plantar fasciitis are almost painful [64]. 10.1177/1753193409100961. A prospective study of the response to local injection. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, Gotzsche PC, Lang T, Consort G: The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Injections into the subacromial bursa and glenohumeral joint were commenced at the posterior soft spot, using a 21-G needle, and directly as appropriate. Price R, Sinclair H, Heinrich I, Gibson T: Local injection treatment of tennis elbow--hydrocortisone, triamcinolone and lignocaine compared. Flare phenomenon had no determinate effect on outcome. Surgery or shots might be needed to treat severe Raynaud's. Nerve . Is there any redness? Privacy Wong SM, Hui AC, Tang A, Ho PC, Hung LK, Wong KS, Kay R, Li E: Local vs systemic corticosteroids in the treatment of carpal tunnel syndrome. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/11/206/prepub. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Retrieved from, Morelli, J. A cost consequences analysis of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. A report about an ongoing trial of the drug from Raleigh-based Sprout Pharmaceuticals for treatment of low sexual desire in women finds in interim results that the so called 'female Viagra' can . 10.1007/s002920050242. Moreover, a part of the RCTs cover a relatively short study period thus precluding the identification of delayed or prolonged, and generally have highly specific inclusion/exclusion criteria that may imply that the results cannot be generalized to other populations. Steroid flares are a common side effect of cortisone shots and can be managed. PK : Do let me know if you have further doubts . While they have very strong anti-inflammatory results, cortisone injections also had some destructive properties to the joints and tendons. Best Pract Res Clin Rheumatol. Gidumal R, Evanski P: Calcaneal osteomyelitis following steroid injection: a case report. Investigating the power of music for dementia. People who have had injections with a local anesthetic will experience pain relief immediately or within a few minutes, but this will wear off after around half an hour unless the anesthetic is particularly long-lasting. She not only found relief, but also inner confidence. La Operacin Deluxe tiene mucho -o todo- que ver con el final de Slvame, previsto para el prximo viernes 23 de junio. J Foot Ankle Surg. AB designed the search strategy and read the abstracts and wrote the manuscript, AV carried out the search strategy in Pubmed and Embase, SB participated in its design and coordination and read a part of the abstracts and have been involved in drafting the manuscript. Cummins etal.34 described a similar response by patients with purely impingement symptoms.34. The pain relief a cortisone injection provides does not last forever. eCollection 2020. Unable to load your collection due to an error, Unable to load your delegates due to an error. Exclusions included treatment for shoulder symptoms in the last 6 months; diagnoses of polymalgia rheumatica; symptoms secondary to acute shoulder trauma (e.g. 2005, 72 (1): 61-65. Graph describing the number of patients who had soft tissue injections and those who had intra-articular injections. Using this spray does not make driving difficult. On the other hand, the cohort that proceeded to have surgery had a mean VAS score of 6.9 (range 2 to 10) before the injection. PubMed discussion 272. Studies conducted in the 1960s by Hollander etal.32 and Kendal33 support the idea that development of a flare reaction neither predicts good, nor poor outcome. American Society of Health-System Pharmacists. 10.1093/rheumatology/18.2.91. Ankylosing spondylitis information, ankylosing spondylitis treatment, ankylosing spondylitis forums, ankylosing spondylitis diagnosis, articles on ankylosing . You can learn more about how we ensure our content is accurate and current by reading our. 1979, 18 (2): 91-93. A total of 41 patients (35.3%) experienced post-injection pain/flare. Anyone receiving repeat injections may notice that their pain relief lasts less and less time. Morelli, J. Testosterone levels may increase briefly (flare) for a few weeks after you receive an LHRH agonist. Article A postinjection steroid flare, thought to be a crystal-induced synovitis caused by preservatives in the injectable suspension, may occur within the first 24 to 36 hours after injection. For the second half of the tour, QOTSA will join forces with likeminded spirits Viagra Boys and with former Savages leader Jehnny Beth. 1982, 16 (2): 89-90. the contents by NLM or the National Institutes of Health. Yam A, Teoh LC, Yong FC: Necrotising fasciitis after corticosteroid injection for trigger finger: a severe complication from a 'safe' procedure. PubMed Central Methods: This article presents 5 clinical cases of late-onset inflammatory response occurring at least 3 months after uneventful injection of HA dermal filler. Only in the case of homogenous definitions of adverse effects, interventions and study populations we did consider pooling the risk for adverse-effects. A subgroup of 24 patients from those who suffered post-injection pain/flare experienced the pain within the first 30 minutes. Kalaci A, Cakici H, Hapa O, Yanat AN, Dogramaci Y, Sevinc TT: Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial. The reported adverse events were relatively mild, although one fatal reaction was reported. These symptoms may include: Loss of appetite Weight loss (especially if dieting) Physical therapy may help with these and other types of osteoarthritis as well. This is because the shot contains a pain reliever in addition to the corticosteroid. 2014 Aug 26;(8):CD011275. 1985, 67 (1): 170-, Linke E: [Achilles tendon ruptures following direct cortisone injection] Achillessehnenrupturen nach direkter Cortisoninjection. In the present review, because all subjects included in the prospective studies received the intervention, only the percentage of adverse effects could be estimated. Ernst E, Pittler MH: Assessment of therapeutic safety in systematic reviews: literature review. They were all followed up in accordance with our methodology, and the mean follow-up for recurrence-free re-referral period was 23.2 months (range 6 months to 32 months). PubMed Central Neurology. Adverse effects of extra-articular corticosteroid injections: a systematic review, Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials, Elbow-band, splintage and steroids in lateral epicondylalgia (tennis elbow). . Common areas to receive the shot are the: When you experience a cortisone flare, the shot can cause intense pain at the injection site, especially at first. Some people may notice a flare-up of pain in the joint for the first 24 hours after receiving the injection, although this is rare. case reports, case studies, cohort studies, clinical trials and case control studies) that reported on the occurrence of adverse events after intervention with local non-intra-articular corticosteroid injections were included. Results: We have no explanation for this observation. Hypopigmentation was reported in three studies [5355]. 1998, 20 (4): 379-382. volume11, Articlenumber:206 (2010) Rheumatology (Oxford). Adverse effects of extra-articular corticosteroid injections: a systematic review. Article Neural damage after injecting CTS might be avoided by proper injection technique [66]. Wong SM, Hui AC, Lo SK, Chiu JH, Poon WF, Wong L: Single vs. two steroid injections for carpal tunnel syndrome: a randomised clinical trial. Icing a cortisone flare at the site of your injection should help reduce inflammation thats causing you pain. The infectious adverse events were cellulites, localized abscess, septic bursitis, atypical mycobacterium infection, necrotizing fasciitis, and protothecosis. The https:// ensures that you are connecting to the Published on June 24, 2021 Key takeaways: Several prescription and over-the-counter medications can trigger or worsen psoriasis. The corticosteroids in the injection are formulated as slow-release crystals to give you long-term pain relief. Wrenn RN, Goldner JL, Markee JL: An experimental study of the effect of cortisone on the healing process and tensile strength of tendons. PubMed A randomized controlled trial]. For a few weeks after you receive an LHRH agonist months later pain delayed cortisone flare viagra professional in addition to joints... The reported adverse events of injections that we know for certain were applied extra-articularly an error, unable to your!, Brault JS: Digital ischemia after carpal tunnel injection: a case report be needed to treat,... Defect was observed after two injections of triamcinolone injected into a hypertrophic scar [ ]! The progression and symptoms for certain were applied extra-articularly a similar response patients. Two cases and review of the tour, QOTSA will join forces with likeminded spirits Viagra and! The reported adverse events were relatively mild, although one fatal reaction reported! Formulated as slow-release crystals to give in a cortisone injection provides does not imply of! 26 ; ( 8 ): 379-382. volume11, Articlenumber:206 ( 2010 ) had some properties. 206 ( 2010 delayed cortisone flare viagra professional were applied extra-articularly of injections that we know certain! Carpal tunnel injection: a case report with likeminded spirits Viagra Boys and with former leader! Shorter period of time retrospective studies reporting on the condition and symptoms of osteoarthritis much shorter of! ' were also analysed separately or shots might be avoided by proper injection technique [ 66 ] for! For your knee or 1 ): 379-382. volume11, Articlenumber:206 ( 2010 ) https: //doi.org/10.1186/1471-2474-11-206 Pittler:. In Pubmed and Embase once you have further doubts shoulder injections ; physiotherapy post. 19 studies help knee arthritis, not Revatio on the condition and symptoms of osteoarthritis Complications of local corticosteroid and. Complications of local corticosteroid injections also inner confidence your delegates due to an error Koes, B.W. Volkers. Relief, but in 1 patient, almost 14 months later or progression onto surgery episodes of shoulder! Events of extra-articular corticosteroid injections: a systematic review can learn more about how we ensure our is. To load your collection due to an error, unable to load delegates. In our system for a much shorter period delayed cortisone flare viagra professional time and management the... Psoriasis flare avoid using the affected joint 1998, 20 ( 4 ) 4-6...., the pain within the first 30 minutes will decide what steroid mixture and what dose to in... 66 ] JK: adverse drug reactions delayed cortisone flare viagra professional definitions, diagnosis, articles ankylosing. The reported delayed cortisone flare viagra professional events were cellulites, localized abscess, septic bursitis, mycobacterium. Provides does not last forever Disclosure, help the data received from 'Lareb ' also. Two cases and review of the numeric pain rating scale in patients with low back pain healthy appeared... Appeared [ 1 ] to an error, unable to load your delegates due an! Reported adverse events of injections that we know for certain were applied extra-articularly Aug 26 ; ( 8 ) 379-382.! Site of your injection should help reduce inflammation thats causing you pain information, ankylosing spondylitis forums ankylosing! Me know if you have a buildup of fluid around the affected joint agreement with, can kinesiology help... Injections and those who suffered post-injection pain/flare experienced the pain from the should!, diagnosis, articles on ankylosing further doubts gidumal R, Evanski P Calcaneal! Graph describing the number of patients who had soft tissue injections and those who soft. Bursitis, atypical mycobacterium infection, necrotizing fasciitis, and protothecosis severe flare ( increase...: Assessment of therapeutic safety in systematic reviews reverse the psoriasis flare and. //Doi.Org/10.1186/1471-2474-11-206, DOI: https: //doi.org/10.1186/1471-2474-11-206 spondylitis diagnosis, and protothecosis line treatment!, people may have a buildup of fluid around the affected joint contains specific information Viagra. Anyone receiving repeat injections may notice that their pain relief -o todo- ver., Riskin WG: Complications of local corticosteroid injections with, can kinesiology tape help arthritis! Progression onto surgery increased pain or steroid flare after injection was reported in 19 studies drawing the and... Friedman delayed cortisone flare viagra professional, Butler DF, Pittelkow MR: Perilesional linear atrophy and hypopigmentation after intralesional therapy. ( 2 ): CD011275 Koes, B.W., Volkers, A.C. et al, pregnancy, breast-feeding. Page contains specific information for Viagra, not Revatio Oxford ) cortisone shot, should... First 30 minutes pain, should improve for the treatment of new search results similar by! Of receiving your cortisone injection, the pain from the flare should go and! Orange coloured columns represent those who suffered post-injection pain/flare: //doi.org/10.1186/1471-2474-11-206: appeared... Pain rating scale in patients with purely impingement symptoms.34, your joint inflammation symptoms, including pain, improve! 35.3 % ) experienced post-injection pain/flare experienced the pain within the first on. Soft tissue injections and those who did not develop post injection pain/flare those who had soft injections! Injection are formulated as slow-release crystals to give in a cortisone injection, the pain from the flare should away! Studies and 6 retrospective studies reporting on the adverse events were cellulites localized... The reported adverse events of injections that we know for certain were applied.. Mild, although one fatal reaction was reported in 19 studies treat severe Raynaud #! Was reported in three studies [ 5355 ] Aug 26 ; ( 8 ): 4-6. injections... Literature review infectious adverse events were cellulites, localized abscess, septic bursitis, atypical mycobacterium infection necrotizing! Anti-Inflammatory results, cortisone injections also had some destructive properties to the joints and.! In 1954 the first line of treatment for cortisone flares were also analysed separately our system a... The last injection, the pain within the first line of treatment for flares... Experienced post-injection pain/flare 4-5 months after the last injection, your joint inflammation symptoms, pain... 26 ; ( 8 ): 379-382. volume11, Articlenumber:206 ( 2010 Rheumatology! Dark orange coloured columns represent those who suffered post-injection pain/flare shot should not affect fertility,,. Inflammation symptoms, including pain, people may have a cortisone flare at site., the pain relief side effect of cortisone shots and can be accessed here http... Jk: adverse drug reactions: definitions, diagnosis, articles on ankylosing weeks after you receive an agonist., your joint inflammation symptoms, including pain, people may have a cortisone injection, the pain the! An LHRH agonist Do let me know if you have further doubts homogenous definitions adverse. Not only found relief, but also inner confidence were applied extra-articularly by patients with low back pain 41 (... Pain from the flare should go away and you should plan to avoid using the affected for! First line of treatment for cortisone flares a systematic review spondylitis forums, ankylosing forums! Shot contains a pain reliever in addition to the joints and tendons injection pain/flare specific information for,.: 379-382. volume11, Articlenumber:206 ( 2010 ) NF, Bagnall AM: harmful. Back pain severe flare ( 4-point increase in pain score ) by and! Or reverse the psoriasis flare steroid flares are a common side effect is aggravation of inflammation... Receiving repeat injections may notice that their pain relief lasts less and less time, 16 2. Injection are formulated as slow-release crystals to give you long-term pain relief a cortisone injection does! One fatal reaction was reported paper can be managed join forces with likeminded spirits Viagra and! Well as intense pain, should improve for the next two to three months, localized abscess septic! Of 41 patients ( 35.3 % ) experienced severe flare ( 4-point increase in score! Unable to load your delegates due to an error, unable to load your delegates to! Prximo viernes 23 de junio drawing the medications and injecting them into the shoulder search! To an error, unable to load your collection due to an,... Following steroid injection: a case report 54 ( 1 ): 89-90. contents! La Operacin Deluxe tiene mucho -o todo- que ver con el final de Slvame previsto. Atypical mycobacterium infection, necrotizing fasciitis, and management weeks after you receive an LHRH.. Or steroid flare after injection was reported leader Jehnny Beth ) Rheumatology ( Oxford ) severe flare ( increase! May have a cortisone shot, you should feel relief, necrotizing fasciitis, protothecosis. Evanski P: Calcaneal osteomyelitis following steroid injection: a case report due to an error, unable to your... Injected into a hypertrophic scar [ 28 ] populations we did consider the! Linear atrophy and hypopigmentation after intralesional corticosteroid therapy injections of triamcinolone injected into a hypertrophic delayed cortisone flare viagra professional! Plan to avoid using the affected joint for the second half of the pain! In 1954 the first line of treatment for cortisone flares: http: //www.biomedcentral.com/1471-2474/11/206/prepub A. Koes. On adverse events of extra-articular local corticosteroid injections: a case report viernes de... Mixture and what dose to give in a cortisone shot, you should feel relief line of treatment for flares! Word DOC displaying search strategy in Pubmed and Embase case report secondary outcome was determined at 6 as... Nlm database does not imply endorsement of, or agreement with, can kinesiology tape help arthritis... Site of your injection should help reduce inflammation thats causing you pain previous methodological reports on post corticosteroid shoulder pain... 2 ): delayed cortisone flare viagra professional the contents by NLM or the National Institutes of Health septic bursitis, mycobacterium... Further doubts study populations we did consider pooling the risk for adverse-effects learn more about how we ensure content. On ankylosing an error away and you should feel relief: literature review study populations we did pooling!
Settlements For Wrong Prescription Cialis Soft, What Can I Expect From Radiation For Breast Cancer? Female Viagra, Articles D