STEROIDS
In a study
of 373 hospice patients 50% received steroids and 40% derived
some benefit from them.
A dose of
dexamethasone 4 mg per day is very useful in most patients to
improve appetite and give a feeling of well-being (but with no
effect on physical weakness). It is important to time this
intervention carefully to avoid side effects, particularly
facial disfigurement.
A trial of high dose steroids has a place in the management of
many different symptoms in terminal care, such as:
-
Superior
vena cava obstruction
-
Dysphagia
from esophageal cancer
-
Vomiting
resistant to anti-emetics
-
Vomiting
from pyloric stenosis
-
Dyspnea
from lymphangitis carcinomatosa
-
Edema
from lymphatic obstruction
A trial of
high dose steroids should last 7 to 10 days to see if symptoms
are going to resolve. The aims of the treatment should be
carefully explained to patient and family, emphasizing that
any improvement in symptoms is likely to be of a temporary
nature.
If the
trial of high dose steroids is successful the dose should be
reduced very gradually (2mg per week) to try to maintain the
symptom control, but minimize the long term side effects. If
the trial of steroids is not effective the steroids should be
stopped (or continued as a low dose for non-specific effect,
such as improved appetite).
Dexamethasone is the steroid of choice in terminal care.
Dexamethasone 4mg per day is the usual dose for anorexia, or
to improve the patient’s feeling of well-being.
Dexamethasone 8mg per day is the usual dose for symptoms of
compression (superior vena cava obstruction, lymphedema,
dysphagia).
Dexamethasone 16mg per day is the usual dose for raised
intracranial pressure.
If the
patient can swallow only liquids, soluble prednisolone
should be used (30mg prednisolone is equivalent to 4mg
dexamethasone).
If the
patient has been on steroids for more than one month, and is
to be weaned off steroids, transfer the patient to
prednisolone so that the dose can be reduced more gradually.
The particular problems in the use of high dose steroids
include:
About 5%
of patients have to stop steroids because of side effects,
particularly facial disfigurement (swelling, hair growth,
acne). The speed at which facial swelling develops is very
variable. The timing of a trial of high dose steroids is
important. High doses for too long can cause considerable
disfigurement (including skin striae, bruising and abdominal
distention).
Oral
thrush can develop rapidly and can be particularly severe
if the patient is on steroids. Consider prophylactic
anti-fungal treatment.
About 5% of
patients develop dyspepsia. Ranitidine 150mg 2 times a
day should then be added, and should be started with steroids
if there is a history of peptic ulceration.
Agitation and restlessness can occur (but psychosis is
rare). Some patients notice that steroids taken late in the
day cause insomnia. Agitation may be controlled by
haloperidol 3mg to 5mg 2 times a day. If not, the steroids
need to be reduced or stopped.
In a known
diabetic steroids will increase insulin requirements. A
trial of high dose steroids is still possible, provided
glucose levels are closely monitored.
Proximal
myopathy can occur after several weeks on high dose
steroids, particularly affecting the quadriceps (difficulty
climbing stairs).
Hyperphagia (a distressing increase in appetite, sometimes
with a craving for food day and night) occurs in about 3% of
patients.
Other rarer
side-effects include myoclonic jerks, cataracts, arthralgias
(on increasing or decreasing the dose) and reactivation of
tuberculosis.
The author and publisher have taken
precautions to ensure that the information in this book is
error-free. However, readers must be guided by their own
personal and professional standards of good practice in
evaluating and applying recommendations made herein. The
contents of this book represent the views and experience of
the author, and not necessarily those of the publisher.
