This site is intended for healthcare professionals

Go to /sign-in page

You can view 5 more pages before signing in

Go to /pro/cpd-dashboard page

This page is worth 0.05 CPD credits. CPD dashboard

Go to /account/subscription-details page

This page is worth 0.05 CPD credits. Upgrade to Pro

Steroids in palliative care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Seek expert advice

  • 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  • corticosteroids may be withdrawn abruptly (abrupt withdrawal of steroids) provided that the patient has: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)

Indications

Treatment and dose range

Spinal cord compression or cauda equina syndrome

Symptoms secondary to cerebral tumour(s). (Headache alone often requires lower dose

nerve compression pain

dexamethasone 16mg per day

dexamethasone 16mg per day

dexamethasone 8mg per day

 

malignant dysphagia

intestinal obstruction

ureteric obstruction

dexamethasone 6-16 mg per day

dyspnoea (pneumonitis after radiotherapy, lymphangitis carcinomatosis, large airways obstruction)

dexamethasone 2-8 mg per day, up to 12mg per day

pain from hepatic metastases

bone pain (occasionally helpful)

dexamethasone 4-8 mg per day

antiemetic

dexamethasone 4-8 mg per day

anorexia*

Dexamethasone 2-4mg / day Prednisolone 15-40mg/day

rectal discharge

rectal steroid preparations, eg hydrocortisone or prednisolone foam enema, or prednisolone suppositories. Once at night.

*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:

Steroid

Route of Administration

Equivalent Anti-inflammatory dose

Dexamethasone

Oral/subcutaneous/IV/IM

2mg

Prednisolone

Oral/rectal

15mg

Hydrocortisone

Oral/IM/IV/rectal

60mg

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

Create an account to add page annotations

Annotations allow you to add information to this page that would be handy to have on hand during a consultation. E.g. a website or number. This information will always show when you visit this page.

The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

Connect

Copyright 2024 Oxbridge Solutions Limited, a subsidiary of OmniaMed Communications Limited. All rights reserved. Any distribution or duplication of the information contained herein is strictly prohibited. Oxbridge Solutions receives funding from advertising but maintains editorial independence.