dexamethasone 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
  • subcutanous 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. This can be done abruptly (abrupt withdrawal of steroids) unless 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 1 - 2mg prednisolone per week)
    • patients should be monitored for any deteriorations

  • 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
    • if beneficial, reduce dose by 25% every 3-5 days as symptoms dictate
  • 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.

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