Bnssg specialist Palliative Care Guidelines for the use of steroids in patients with cancer

Bristol Palliative Care Collaborative

Palliative care guidelines for the use of steroids in patients with cancer

Introduction

These guidelines are intended to promote the safe prescribing of steroids in patients with cancer. Steroids are one of the most common group of drugs prescribed for patients seen by Specialist Palliative Care (SPC) teams¹ but have the potential for causing harm due to side effects.

General principles

1. 
   There should be a clear clinical indication for the steroid and the starting dose should follow local clinical guidelines for that indication
   

2. 
   A discussion should take place between the SPC team member recommending or prescribing steroids and the patient about the potential side effects of steroids. This should be recorded in the patient’s notes
   

3. 
   Patients likely to be on steroids for more than 3 weeks should be told they will need to carry a steroid card
   

4. 
   The clinical response to the steroid should be assessed approximately 5-7 days after commencement. A plan for continuation, including weaning to the lowest dose necessary to achieve the desired effect, or stopping should then be agreed with the patient and documented in the notes
   

5. 
   Patients who commence steroids in hospital should have clear instructions about dosage and continuation/weaning on discharge and this should be communicated to the GP
   

6. 
   Patients taking >6mg of dexamethasone (or equivalent dose of prednisolone or hydrocortisone) should have either urinalysis or a BM check regularly (e.g. weekly)²
   

7. 
   Patients who are also taking a non-steroidal anti-inflammatory drug should have gastro-protection prescribed according to local guidelines.
   

8. 
   Patients receiving long term steroids (e.g. >3 weeks) should have the dose temporarily increased during significant intercurrent infection, trauma or surgery as they are at risk of adrenal crisis^3,4
   

9. 
   It is recommended that steroids are taken before 14.00 in order to reduce the chance of steroids contributing to insomnia⁵
   

10. 
    Consider whether prophylaxis against osteoporosis (e.g. by calcium, vit D and oral bisphosphonates) is needed in patients on long-term steroids (>3 months) and/or a bone densitometry scan to assess risk⁵
    

11. 
    Doses may need to be increased if patients are also taking enzyme-inducers, e.g. phenytoin. In addition, phenytoin levels can be reduced by corticosteroids and doses may need to be adjusted⁶