Corticosteroids

Corticosteroids

•  Patients with advanced malignancy may benefit from corticosteroids for a variety of symptoms. There should always be a clear indication to justify starting corticosteroids and benefits should always be balanced against the side effects, such as diabetes, proximal myopathy, candidiasis, osteoporosis

•  Doses should be tailored to the individual and regularly reviewed, as responses may not be prolonged

•  Each stage of the corticosteroid plan should be documented, e.g. indication(s), expected outcome(s), and expected response time. Risk to benefit should be considered for each patient1

•  Dexamethasone is the corticosteroid of choice. There are however few trials on which to base guidance for indications and dosing. Dose ranges in common use are shown in the table below2,3

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•Prescribe as a single morning dose or twice daily doses with last dose before 2 pm. (This reduces suppression of hypo-pituitary-adrenal axis and may prevent corticosteroid induced insomnia)

•Higher than usual doses may be required for patients on phenytoin, carbamazepine, phenobarbitone

•Use a 5–7 day corticosteroid ‘trial’ and unless desired effect achieved, corticosteroid should be stopped

 

Abrupt withdrawal of corticosteroids⁴

Corticosteroids may be withdrawn abruptly provided that the patient has:

• received less than 3 weeks treatment and
• not received recent repeated courses of corticosteroids and
• received doses less than 4-6mg dexamethasone
(or equivalent) total daily dose and
• adverse effects are not anticipated by an abrupt withdrawal.

 

Gradual withdrawal of corticosteroids⁴

•Initially reduce rapidly (e.g. halving the dose daily) to physiological doses (dexamethasone 1mg/24h or prednisolone 7.5mg/24h)

•Subsequently more gradual reduction is advised (e.g. by 1–2mg prednisolone per week)

•Patients should be monitored for any deteriorations

If beneficial, corticosteroids should only be continued at
a set dose for a maximum of 2–4 weeks,
with planned review date to consider withdrawal.
Aim to prescribe the lowest dose that controls the symptoms.

 

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•If oral route is no longer available, dexamethasone may be given by infusion but may need to be given in a separate syringe driver (see syringe driver compatibility chart Appendix I) or as a stat subcutaneous dose depending on volume

•The oral bioavailability of dexamethasone tablets is 80%, compared with intravenous doses7. There is no published literature comparing oral and subcutaneous administration. Generally oral and subcutaneous doses are considered equivalent. Other sources state dexamethasone to be twice as potent by the subcutaneous route, compared to oral8

•Where patients have recently discontinued corticosteroids consider additional doses for any circumstances involving physiological stress (pain, infection, trauma)

•It may be appropriate to stop corticosteroids in the last days of life unless they have been essential in achieving good symptom control for the patient e.g. to manage headaches, seizures or pain

What should the patient be told?
•Give patient a steroid card if they do not already carry one

•Explain the reason(s) for prescribing steroid, including anticipated benefits and side effects

•Take early in the day

•Don’t stop suddenly, especially if steroids have been taken for more than 3 weeks – give a plan for dose reduction

•Improvement does not mean tumour regression

•To seek medical help if more unwell while taking corticosteroids, or come into contact with infectious disease (as recommended on steroid card)

•Vigilance for oral thrush

 

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References
1. NICE Guidelines (2004). Improving Supportive Palliative Care for Adults with Cancer.
2. Wooldridge JE et al (2001). Corticosteroids in advanced cancer. Oncology 15:225.
3. Twycross R, Wilcock A (Eds). Palliative Care Formulary: Fourth Edition. Palliativedrugs.com Ltd 2011.
4. Committee on Safety of Medicines and Medicines Control Agency Expert Working Group. Withdrawal of systemic corticosteroids. Current Problems in Pharmacovigilance 1998: 24 (May) 5.
5. Piper JM et al (1991). Corticosteroid use and peptic ulcer disease: role of non-steroidal anti-inflammatory drugs. Ann Intern Med 114:735.
6. Joint Formulary Committee (British Medical Association and Royal Pharmaceutical Company). British National Formulary (BNF 62). bnf.org 2011.
7. Duggan D E et al (1975). Bioavailability of oral dexamethasone. Clinincal Pharmacy and Therapeutics 18(2):205-209.
8. Back I. (2001). Palliative Medicine Handbook 3rd Ed. BPM Books.
9. Feuer DDJ, Broadley KE.Corticosteriods for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer (Review). Cochrane Database of Systematic Reviews 2000, Issue