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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- corticosteroids may be withdrawn abruptly (abrupt withdrawal of steroids) provided that the patient has: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
The approximate equivalent potencies for common steroids are as follows:
- Dexamethasone: 0.75 mg
- Prednisolone: 5 mg
- Hydrocortisone: 20 mg
This means that dexamethasone is approximately seven times stronger than prednisolone (e.g., 2mg dexamethasone = 15mg prednisolone) and has a longer biological half-life of 36-54 hours compared to prednisolone's 12-36 hours.
The respective summary of product characteristics must be checked before prescribing the drugs described.
Reference:
- WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain In Adults and Adolescents, 2018.
- West Midlands Palliative Care Physicians (2024). Palliative care - guidelines for the use of drugs in symptom control