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



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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



  1. 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



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



  1. 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



  1. 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



  1. 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



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



  1. 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 crisis3,4



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



  1. 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



  1. 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


Indications_and_doses_6'>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 7th 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/Discontinuation9,10

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 4th 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


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