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

Indications and doses⁶

The list of indications is not exhaustive and the doses stated are usual, but not prescriptive, starting doses. For further information see The Palliative Care Handbook: Advice on clinical management in palliative care patients 7^th Edition October 2010⁷

Indication	Steroid dose
Anorexia	2-4mg
Fatigue
Malignant bowel obstruction	4-8mg
Nerve compression pain
Liver capsule pain
Nausea
Lymphangitis carcinomatosis Rapidly expanding bone mets
Malignant spinal cord compression (MSCC)^8	8-16mg
Superior vena cava obstruction Large airway obstruction
Brain metastases

Reduction/Discontinuation^9,10

No clear evidence exists for specific tapering regimens, although it is clear that in many patients steroids should not be stopped abruptly¹⁰. The following notes are therefore suggestions:

1. In patients taking <4mg dexamethasone for <3 weeks it is generally safe to stop steroids abruptly unless :

Patient has had repeated courses of systemic corticosteroids

A short course has been prescribed within one year of cessation of long-term therapy (months or years)

Patients who may have reasons for adrenocortical insufficiency other than exogenous corticosteroid therapy

2. If a patient has taken dexamethasone for >3 weeks, reduction needs to be gradual and should be guided by whether the original indication is likely to relapse as steroids are reduced. If the latter is not likely to occur, suggest:

Dex >2mg daily – reduce dose by half every 3-5 days

Dex < 2mg daily – reduce dose by 0.5mg every 5-7 days.

If relapse is a concern, reduce more slowly.

Separate reduction guidelines are available for patients receiving whole brain radiotherapy or radiotherapy for spinal cord compression¹¹:

At the end of life

If unable to take oral medications, consider the balance of benefits and burdens of subcutaneous injections versus possible steroid withdrawal reaction

• 
  If steroids have been essential in achieving good symptom control (e.g. headaches secondary to raised intracranial pressure) then the balance of benefits/burdens likely to be in favour of continuing steroids
  
• 
  Injection strength is 3.3mg/ml or 3.8mg/ml, depending on brand. Oral bioavailability of dexamethasone is ~80%¹². For pragmatic reasons a 4mg PO dose can be considered roughly equivalent to 3.3mg or 3.8mg SC, depending on which preparation is available.
  
• 
  Dexamethasone may be given as a single daily SC injection, preferably in the morning, if volume of injection is 2ml or less.
  
• 
  Alternatively for higher doses dexamethasone can be administered via a syringe pump. It is incompatible with most other drugs so a second syringe pump is usually required.
  

Dose equivalence⁶

	Prednisolone	Dexamethasone
Approximate equivalent dose	5	0.5 -1
Anti-inflammatory potency	5	25-50
Oral bioavailability	75-85%	78%
Onset of action	No data	8-24 hours I.M.
Duration of action	12-36 hours	36-54 hours
Sodium retaining potency	0.25	<0.01
Daily dose above which adrenal suppression likely	7.5mg	1mg

Side effects

Diabetes mellitus, osteoporosis, avascular bone necrosis, mental disturbances – insomnia, paranoid psychosis, depression, euphoria, muscle wasting and weakness (typically proximal and after 3 months of dexamethasone >4mg daily although may occur sooner), peptic ulceration (if given with an NSAID), increased susceptibility to infection, sodium and water retention, potassium loss, hypertension and Cushing's syndrome.

References:

1. Shih A. Jackson KC. Role of corticosteroids in palliative care. Journal of Pain & Palliative Care Pharmacotherapy. 21(4):69-76, 2007

2. Pilkey et al. Corticosteroid-induced diabetes in palliative care. Journal of Palliative Medicine. 15(6):681-9, 2012

3. Peacey SR. Pope RM. Naik KS. Hardern RD. Page MD. Belchetz PE. Corticosteroid therapy and intercurrent illness: the need for continuing patient education. Postgraduate Medical Journal. 69(810):282-4, 1993

4. BNF (2011) Section 6.3.2 in: British National Formulary no 61. British Medical Association and the Royal Pharmaceutical Association of Great Britain, London

5. Extracted from: Glucocorticoid-induced osteoporosis: a concise guide for prevention and treatment. London: Royal College of Physicians, 2002. https://www.rcplondon.ac.uk/sites/default/files/documents/glucocorticoid-induced-osteoporosis-concise.pdf accessed 10/9/14

6. Twycross R, Wilcock A. Palliative Care Formulary 4^th ed: palliativedrugs.com 2011. Chapter 7 p483-92

7. Available at: http://www.ruh.nhs.uk/For_Clinicians/departments_ruh/Palliative_Care/documents/palliative_care_handbook.pdf

8. MSCC guidelines available at: http://publications.nice.org.uk/metastatic-spinal-cord-compression-cg75/guidance#treatment-of-spinal-metastases-and-mscc

9. CSM (committee on safety of medicines and medicines control agency) 1998: Withdrawal of systemic corticosteroids. Current problems in Pharmacovigilance. 24: 5-7

10. Margolin L. Cope DK. Bakst-Sisser R. Greenspan J. The steroid withdrawal syndrome: a review of the implications, etiology, and treatments. Journal of Pain & Symptom Management. 33(2):224-8, 2007

11. http://nww.avon.nhs.uk/dms/download.aspx?did=9498

12. Duggan D E et al (1975). Bioavailability of oral dexamethasone. Clinical Pharmacy and Therapeutics 18(2):205-209

BPCC Steroid Guidelines Authors: R Bhatia and C Reid Review April 2016