What should the patient be told?

Corticosteroids may be withdrawn abruptly provided that the patient has: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 method

1. Initially reduce rapidly (e.g. halving the dose daily) to physiological doses (dexamethasone 1mg/24h or prednisolone 7.5mg/24h).

2. Subsequently more gradual reduction is advised (e.g. by 1mg–2mg prednisolone per week).

3. Patients should be monitored for any deterioration, in particular for signs of adrenal insufficiency.

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 oral route is no longer available

• Dexamethasone may be given by infusion but may need to be given in a separate syringe driver/pump (See Chapter: Syringe driver) or as a stat subcutaneous dose depending on volume. If volume of a stat injection of dexamethasone would be more than 2ml, then the same injection can be split between two different sites e.g. left arm and right arm to allow more comfortable once daily administration.

• The oral bioavailability of dexamethasone tablets is 80%, compared with intravenous doses. There is no published literature comparing oral and subcutaneous administration. Generally oral and subcutaneous doses are considered equivalent. Other sources state dexamethasone to be twice as potent by the subcutaneous route, compared to oral.

• It may be appropriate to stop corticosteroids in the last days of life unless they have been essential in achieving good symptom control for the patient e.g. to manage headaches, seizures or pain.