Steroids in palliative care

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• patients with advanced malignancy may benefit from corticosteroids for a variety of symptoms
• doses should be tailored to the individual and regularly reviewed, as responses may not be prolonged
• emergency situations, eg spinal cord compression/superior vena cava obstruction - consider IV dexamethasone initially as stat dose, give slowly
• subcutaneous route in vomiting (daily bolus)
• dexamethasone is the corticosteroid of choice.
  • the bioavailability of dexamethasone is 80%. Generally oral and subcutaneous doses are considered equivalent. Other sources quote dexamethasone to be twice as potent by the subcutaneous route, compared to oral
  • where patients have recently discontinued corticosteroids consider additional doses for any circumstances involving physiological stress (pain, infection, trauma)
• prescribe as a single morning dose (or two morning doses if numerous tablets required)
• consider a higher dose of corticosteroids initially to ensure any effect not missed and review after 3-5 days. Consider the need for higher doses for patients on phenytoin, carbamazepine, phenobarbitone
  
  
• use a 5-7 day corticosteroid 'trial' and unless desired effect achieved, corticosteroid should be stopped
• corticosteroids may be withdrawn abruptly (abrupt withdrawal of steroids) provided that the patient has: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
    
    
• gradual withdrawal of corticosteroids
  • initially reduce rapidly (e.g. halving the dose daily) to physiological doses (dexamethasone 1mg/24h or prednisolone 7.5mg/24h)
  • subsequently more gradual reduction is advised (e.g. by 1mg–2mg prednisolone per week)
  • 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

• watch for symptoms e.g. increased thirst, increased frequency of micturition which might indicate hyperglycaemia
• consider prescribing gastric protectants (e.g. lansoprazole 15- 30mg daily) if at risk (e.g. on a concurrent NSAID, previous history of peptic ulcer disease)

*a progestogen may be more appropriate as an agent to treat anorexia for long term use, for example:

• Megesterol acetate 80-160mg OD PO in the morning or Medroxyprogesterone acetate 400mg OD to BD PO in the morning

Parenteral Dexamethasone:

• given SC or IV, dose depends on indication
• precipitates easily so usually best to give in separate syringe

Approximate relative potencies of steroids:

The respective summary of product characteristics must be checked before prescribing the drugs described.

Reference:

1. West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control
2. Dr Michael Cushen, St Elizabeth Hospice, Ipswich 5/9/96
3. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.
4. West Midlands Palliative Care Physicians (2024). Palliative care - guidelines for the use of drugs in symptom control