Principles of corticosteroid use

There should always be a clear indication to justify starting corticosteroids and benefits should always be balanced against the side effects.

  • Doses should be tailored to the individual and regularly reviewed, as responses may not be prolonged.
  • Each stage of the corticosteroid plan should be documented and shared with relevant health care professionals, e.g. indication(s), expected outcome(s), and expected response time. Risk vs benefit should be considered for each patient.
  • Side effects include diabetes, proximal myopathy, candidiasis, osteoporosis, pseudorheumatism, peptic ulceration, salt and fluid retention, Cushingoid features, sleep and psychiatric disturbance.
  • Dexamethasone is the corticosteroid of choice. There are however few trials on which to base guidance for indications and dosing.
  • Where possible prescribe as a single morning dose. If not practical, use twice daily doses with last dose before 2 pm. (This reduces suppression of hypo-pituitary-adrenal axis and may prevent corticosteroid induced insomnia).
  • Use a 5–7 day corticosteroid ‘trial’ and unless desired effect achieved, corticosteroid should be stopped.
  • Prescribe a gastro-protective agent such as PPI or Ranitidine.
  • 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.
  • Vigilance for oral thrush is needed.

Steroids are contraindicated in:

  • Systemic infection, unless considered to be lifesaving and specific anti-infective therapy is employed.
  • Active GI bleeding.
  • Previous steroid-induced psychosis.

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.