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