16.4 Corticosteroids in palliative care

  1. Some patients with advanced malignancy benefit from steroids for a variety of symptoms.

Dexamethasone is used in preference to prednisolone in palliative care when high dose anti-inflammatory therapy may be required (it has insignificant mineralocorticoid effect so is less likely to cause fluid retention).

Dexamethasone 1mg is equivalent to prednisolone 7.5mg.

Approximate equivalent anti-inflammatory doses of corticosteroids:

  • Hydrocortisone 20mg
  • Prednisolone 5mg
  • Methylprednisolone 4mg
  • Betamethasone 750 micrograms
  • Dexamethasone 750 micrograms

Starting corticosteroids

In practice the bioavailability of oral and parenteral routes are essentially equivalent, therefore use oral steroids where possible.

Aim to prescribe the lowest dose that controls the symptoms. Review regularly and reduce the dose as indicated. The dose may be given as a single dose in the morning, or in two divided doses, the second dose taken before 2.00pm (to avoid insomnia).

Advise the patient to take their corticosteroid with food. Prescribe gastroprotection, usually a PPI, if the patient is at risk of a gastrointestinal event or is also taking an NSAID or anticoagulant.

Check urinalysis for glucose intolerance after 72 hours and again if appropriate

Subcutaneous dexamethasone can be used for those patients who are unable to take oral medications but who are benefiting from steroid therapy e.g. symptom control for patients with brain metastases. In these situations give as a once or twice daily injection (avoiding an evening dose to reduce the risk of insomnia). The recommended maximum single subcutaneous injection is 2mL.

4mg/mL dexamethasone ampoules are no longer available. 3.3mg/mL (supplied by Hameln and Hospira) is the most widely available preparation currently; supplies of 3.8mg/mL (Aspen) also available in some places.

When switching from oral dexamethasone to a subcutaneous dose, we would recommend prescribing equivalents as below.

Prescribing equivalents oral and subcutaneous dexamethasone (adapted from Palliativedrugs.com)

  • Anorexia
    • Oral: 2mg - 4mg
    • SC/IV dose (volume)
      • 3.3mg/mL formulation: 1.7mg - 3.3mg (0.5mL - 1mL)
      • 3.8mg/mL formulation: 1.9mg - 3.8mg (0.5mL - 1mL)
  • Antiemetic
    • Oral: 4mg - 8mg
    • SC/IV dose (volume)
      • 3.3mg/mL formulation: 3.3mg - 6.6mg (1mL - 2mL)
      • 3.8mg/mL formulation: 3.8mg - 7.6mg (1mL - 2mL)
  • Obstruction of hollow viscus
    • Oral: 8mg - 16mg
    • SC/IV dose (volume)
      • 3.3mg/mL formulation: 6.6mg - 13.2mg (2mL - 4mL)
      • 3.8mg/mL formulation: 7.6mg - 15.2mg (2mL - 4mL)
  • Raised intracranial pressure
    • Oral: 8mg - 16mg
    • SC/IV dose (volume)
      • 3.3mg/mL formulation: 6.6mg - 13.2mg (2mL - 4mL)
      • 3.8mg/mL formulation: 7.6mg - 15.2mg (2mL - 4mL)
  • Spinal cord compression
    • Oral: 16mg
    • SC/IV dose (volume)
      • 3.3mg/mL formulation: 13.2mg 4mL)
      • 3.8mg/mL formulation: 15.2mg (4mL)

If adding low dose dexamethasone to syringe pump for site reactions, use:

  • Dexamethasone 0.2mL - 0.3mL (0.66mg - 0.99mg) of 3.3mg/mL preparation
  • Dexamethasone 0.2mL - 0.3mL (0.76mg - 1.14mg) of 3.8mg/mL preparation

Indications

  • Compression Syndromes (malignant spinal cord compression, superior vena cava obstruction, malignant dysphagia, obstruction of hollow viscus) (see above)
  • Brain metastases(see above)
  • Dyspnoea (pneumonitis after radiotherapy, carcinomatous lymphangitis)
    • Starting dose: PO dexamethasone 2-8mg /day
  • Rectal discharge
    • Colifoam® enema 1 dose (125mg) twice daily
  • Pain (hepatic metastases, nerve compression, bone pain) (see above)
  • Anorexia (see above)
  • Antiemetic (see above)

Side effects

  • Oral thrush
  • Dyspepsia
  • Muscle wasting and weakness (proximal myopathy)
  • Agitation
  • Psychiatric disturbances (depression, mania, paranoia and delirium)
  • Insomnia
  • Impaired glucose tolerance (steroid induced diabetes mellitus or deterioration of glycaemic control in a known diabetic)
  • Fluid retention
  • Infection
  • Cushingoid features (lipodystrophy, acne, bruising, hirsuitism, striae)
  • Osteoporosis
  • Avascular bone necrosis
  • Hypertension

Discontinuing corticosteroids

If the patient has been on the equivalent of 40mg/day or more of prednisolone (Dexamethasone 6mg) for longer than 1 week, has received treatment for longer than 3 weeks, recently received repeated courses or has had a short course of treatment within 1 year of stopping long-term corticosteroids their dose must be tailed off gradually rather than stopping abruptly.

For patients in the last few hours or days of life, the inability to swallow oral medication is often the factor leading to discontinuation of their corticosteroid treatment. However, for some individuals e.g. patients with brain metastases and significant symptoms that have benefited from steroid use, it may be appropriate to continue with a daily dose of subcutaneous corticosteroid until the patient is unconscious/unaware.

Key Messages

Document a clear plan when starting corticosteroids i.e. indication, dose, duration and discontinuation

Monitor for side effects

Aim to use the lowest dose for the shortest time

The patient should carry a steroid card and be told not to abruptly stop their treatment unless directed to do so.

 

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