Corticosteroids (Palliative Care) Guidance

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients over 18 years of age
  • Use of steroids in advanced malignancy only

This guidance does not cover:

  • Patients under 18 years of age
  • Use of steroids to actively treat malignancy

Corticosteroid Treatment

Key Messages
  • Document a clear plan when starting corticosteroids i.e. indication, dose, duration and discontinuation. Be clear about which healthcare professional is responsible for ongoing review.
  • 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.Some patients with advanced malignancy benefit from steroids for a variety of symptoms.
Overview
  • Dexamethasone is used in preference to prednisolone in palliative care when high dose anti­inflammatory therapy may be required (it has insignificant mineralocorticoid effect so is less likely to cause fluid retention).
  • Approximate equivalent anti-inflammatory doses of corticosteroids are:
    • Hydrocortisone 20mg
    • Prednisolone 5mg
    • Methylprednisolone 4mg
    • Betamethasone 750 micrograms
    • Dexamethasone 750 micrograms
Starting and discontinuing Corticosteroid
  • 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. Aim to give steroids as a single dose in the morning, but if two divided doses are required due to tablet burden, the second dose should be 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 taking other medications with an increased risk of GI bleeding e.g. NSAIDS, anticoagulants, SSRIs. Be aware that concurrent use of steroids usually leads to an increase in INR in patients already taking warfarin.
  • Morning steroids tend to cause a late afternoon or early evening rise in blood glucose levels. Consider blood glucose monitoring at least once a week or more frequently in patients with pre-existing diabetes or those at high risk of impaired glucose tolerance.
  • 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.
  • Injectable Dexamethasone is most widely available in the 3.3mg/mL preparation (supplied by Hameln and Hospira); supplies of 3.8mg/mL (Aspen) are also available in some places.
  • When switching from oral dexamethasone to a subcutaneous dose, we would recommend prescribing equivalents as below:

Oral Dexamethasone dose

Dexamethasone 3.3mg/ml dose

Dexamethasone 3.8mg/ml dose

2mg

1.65 mg (0.5ml)

1.9mg (0.5 ml)

4mg

3.3 mg (1 ml)

3.8mg (1 ml)

6mg

4.95 mg (1.5ml)

5.7 mg (1.5 ml)

8mg

6.6 mg (2 ml)

7.6 mg (2 ml)

12mg

9.9 mg (3 ml)

11.4 mg (3ml)

16mg

13.2 mg (4 ml)

15.2mg (4 ml)

  • 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 long­term corticosteroids their dose must be tailed off gradually rather than stopping abruptly. For this reason, it is suggested that new courses of steroids in patients who have not used them previously, are reviewed for benefit after 5 day and stopped at that point it nil is seen.
  • 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.
Indications & Suggested Starting Doses
  • Steroids are used for a variety of indications in advanced malignancy but it is important to be aware that many of these are "off label" and therefore particular care should be taken to assess for benefit.
  • The following are indications and recommended oral starting doses unless otherwise stated:
  • Malignant Spinal Cord Compression
    • Dexamethasone 16mg orally once daily
  • Malignant Bowel Obstruction
    • In inoperable cases, steroids can be considered to reduce peri-tumour oedema but oral absorption is likely to be poor in the presence of bowel obstruction. This should only be given under specialist advice.
    • Dexamethasone 6.6 mg (3.3mg/ml preparation) or 7.6 mg (3.8mg/ml preparation) subcutaneously once daily
    • Due to risk of perforation and GI bleed consider discussion with palliative care team
  • Bronchial obstruction secondary to tumour
    • Consider Dexamethasone 16mg orally once daily whilst organising definitive treatment but evidence is limited to case series.
  • Superior Vena Cava Obstruction
    • Evidence for using corticosteroids as a holding measure prior to definitive treatment is lacking. Where used, they should be for a limited duration and discussion with local respiratory or oncology teams is recommended first.
    • Dexamethasone 16mg orally once daily
  • Brain Metastases
    • Steroids have a role in reducing raised intra-cranial pressure and this is one of the licensed indications for Dexamethasone
    • Use Dexamethasone 4- 8 mg orally once daily unless symptoms are severe or there is there is risk of herniation, in which case use Dexamethasone 16 mg orally once daily
  • Malignant Dysphagia
    • Steroids may help temporarily if there is an obstruction due to tumour.
    • Use Dexamethasone 8mg orally once daily
  • Lymphangitis Carcinomatosis
    • Evidence of the effectiveness of steroids in lymphangitis carcinomatosis is lacking, but a trial of steroids may be considered if patients are symptomatic.
    • Commence Dexamethasone 8- 12 mg orally once daily but stop after 1 week if not effective.
  • Pain
    • Steroids are not usually a first line analgesic but they may be helpful for pain due to liver capsule stretch secondary to hepatic metastases, nerve root compression or bone metastases, where other analgesics are proving insufficient.
    • Use Dexamethasone 4- 8 mg orally once daily
  • Anorexia and fatigue
    • There is some low quality evidence of benefit for this indication, in the short term only.
    • Commence Dexamethasone 2- 4 mg orally once daily
  • Anti-emetic
    • Outside of the context of raised intracranial pressure or severely emetogenic chemotherapy, steroids are not a first line treatment for nausea and vomiting.
    • Discussion with the Specialist Palliative Care team is advised if steroids are being considered for other causes of nausea and vomiting
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)
  • GI ulceration, bleeding and perforation (Suggest co-prescription of gastroprotection)
  • Fluid retention
  • Infection
  • Cushingoid features (lipodystrophy, acne, bruising, hirsuitism, striae)
  • Osteoporosis (the BNF suggests considering prophylaxis if a patient will be taking steroids for >3 months)
  • Avascular bone necrosis
  • Hypertension

Referral

Referral Criteria

Wakefield CCG
  • Eligibility for referral to specialist palliative care services (including inpatient, community, day hospice or outpatient service provision) is based on patient need not diagnosis:
    • The patient has active, progressive and usually advanced disease for which the prognosis is limited (although this may be several years) and the focus of care is quality of life.
    • The patient has unresolved complex needs that cannot be met by the caring team. These needs may be physical, psychological, social and /or spiritual. Examples may include complicated symptoms, difficult family situations, or ethical issues regarding treatment decisions.
  • Patients who meet the above criteria may be admitted to any part of the specialist palliative care service as required
  • An eConsultation request can also be sent via SystmOne
  • See palliative care contact details and resources for further information
North Kirklees
  • Common eligibility criteria were agreed in 2000 by all providers of SPC (specialist palliative care) working in Calderdale and Kirklees in order to ensure equity of access. The criteria reflects those adopted by other SPC services across the country and was incorporated into the new service agreement with Kirkwood on April 2015.
  • There are three elements to the common eligibility criteria:
    • Patients should have active, progressive and potentially life-threatening illness
    • Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical
    • Patients must have been recently assessed by a member of a SPC team
  • See palliative care contact details for further information

Referral Forms

Wakefield CCG
North Kirklees CCG

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Supporting Information

Useful Links

Hospice information
Other

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 07.2019
  • Ref No: PL5 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
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