Use Of Corticosteroids In Palliative Care From West Midlands Palliative Care

Today, I review and link to the chapter on steroid use from Guidelines for the use of drugs in symptom control from West Midlands Palliative Care.

All that follows is from the above resource.

Principles of corticosteroid use

There should always be a clear indication to justify starting corticosteroids and benefits should always be balanced against the side effects.

  • There should be a clear indication to justify starting corticosteroids.
  • Doses should be tailored to the individual.
  • Regular review is essential as responses may not be prolonged.
  • Each stage of the corticosteroid plan should be documented and shared with relevant health care professionals, e.g., indication(s), expected outcome(s), and expected response time.
  • Dexamethasone is the corticosteroid of choice. There are however few trials on which to base guidance for indications and dosing.
  • Use a 5–7 day corticosteroid ‘trial’ and unless desired effect achieved, corticosteroid should be stopped.
  • 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.
  • Where possible prescribe as a single morning dose. If not practical, use twice daily doses with last dose before 2 pm. (This reduces suppression of hypo-pituitary adrenal axis and may prevent corticosteroid induced insomnia).
  • Aim to prescribe the lowest dose that controls the symptoms.
  • Side effects include candidiasis, diabetes, proximal myopathy, osteoporosis, pseudo rheumatism, peptic ulceration, salt and fluid retention, cushingoid features, sleep and psychiatric disturbance.
  • Prescribe a gastro-protective agent such as a PPI.
  • Vigilance for oral thrush is needed.
  • Steroids are contraindicated in:
    • Systemic infection, unless considered to be lifesaving and specific anti-infective therapy is employed.
    • Active GI bleeding.
    • Previous steroid-induced psychosis.

Choosing the right dose

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.

Neurological

Spinal cord compression or cauda equina syndrome

Dexamethasone: 16mg/day

Symptoms secondary to cerebral tumour(s).

Dexamethasone: 16mg/day
(4mg-8mg often sufficient for headache. More than 16mg may be required for patients with high risk of coning, or those taking enzyme inducing medications e.g. phenytoin, carbamazepine, phenobarbitone)

Nerve compression pain

Dexamethasone: 8mg/day

Respiratory

Superior vena caval obstruction SVCO

Dexamethasone: 16mg/day

Dexamethasone: 16mg/day

Lymphangitis carcinomatosa

Dexamethasone: 16mg/day

Large airways obstruction

Dexamethasone: 16mg/day

Gastrointestinal Tract

Dysphagia

Dexamethasone: 6mg-16mg/day

Intestinal obstruction

Dexamethasone: 6mg-16mg/day

Rectal discharge

Rectal corticosteroid preparations e.g. hydrocortisone or prednisolone foam enema, or prednisolone suppositories. Once at night.

Miscellaneous

Ureteric obstruction/pelvic disease.

Dexamethasone: 6mg-16mg/day

Dexamethasone: 4mg-8mg/day

Bone pain (occasionally helpful)

Dexamethasone: 4mg-8mg/day

Anorexia/to improve wellbeing (short term)

Dexamethasone: 2mg–4mg / day Prednisolone 15mg–40mg/day

Monitoring

Check capillary blood glucose before starting steroids (to assess risk) and within 7 days of commencing steroids continue monitoring on a regular basis while the patient remains on steroids. Monitor for symptoms which might indicate hyperglycaemia e.g. increased thirst, increased frequency of micturition.

If hyperglycaemia is present, seek medical or specialist advice regarding management of hyperglycaemia in palliative care.

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).
  • Try to take steroids with or after food, or a hot drink, to reduce any stomach irritation.

Withdrawal

What should the patient be told?

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.

*Steroid Conversion Calculator from MD Calc
Converts steroid dosages using dosing equivalencies.

Gradual withdrawal of corticosteroids method

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

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

3. Patients should be monitored for any deterioration, in particular for signs of adrenal insufficiency.

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.

If oral route is no longer available

  • Dexamethasone may be given by infusion but may need to be given in a separate syringe driver/pump (See Chapter: Syringe driver) or as a stat subcutaneous dose depending on volume. If volume of a stat injection of dexamethasone would be more than 2ml, then the same injection can be split between two different sites e.g. left arm and right arm to allow more comfortable once daily administration.
  • The oral bioavailability of dexamethasone tablets is 80%, compared with intravenous doses. 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 oral.
  • 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.

Preparations and dose equivalence

Corticosteroids References

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