Corticosteroids are often prescribed to deal with palliative care symptoms.
Dexamethasone is often selected in palliative care given its prolonged half-life, multiple routes of administration, and relatively low mineralocorticoid effect. Prednisone, prednisolone, and methylprednisolone are preferred in liver impairment.
Routes of administration and equivalent doses
Dexamethasone IM, IV, O, SC: 0.75 mg
Methylprednisolone IM, IV, O: 8 mg
Prednisolone O solution: 5 mg
Prednisone O: 4-6 mg
Although the risk of adverse effects increases with dose and duration of any corticosteroid, long-term treatment (e.g., longer than a month) with relatively low doses (prednisone 5 mg or less) is generally well tolerated.
• Early adverse effects (days): hyperglycemia, fluid retention, and mental disturbances.
• Late adverse effects (weeks to months): myopathy leading to proximal limb muscle weakness and reduced respiratory force, infection risk (especially fungal such as oral thrush), and additive risk of GI bleed with NSAIDS.
Considerations when prescribing corticosteroids
• Monitor regularly. Aim to discontinue corticosteroids within 5-7 days if there is an insufficient clinical response: it is a way to prevent the need to reduce the dose gradually.
• Aim for the lowest therapeutic dose to prevent side effects. If taking ≤ 4 mg of dexamethasone (or its equivalent) for 3 weeks or less, it is likely safe to stop steroids abruptly without a taper.
• Unless an emergency, most corticosteroids can be administered once daily in the morning, or twice daily with the last dose before 2 p.m. This dosage schedule reduces suppression of the hypo-pituitary-adrenal axis and the risk of insomnia.
• Consider prognosis. Side effects become a cumulative problem when prognosis is months or more.
• Monitor for hyperglycemia, especially in patients with an anticipated prognosis of months or more.
• Consult an oncologist before starting corticosteroids, as they may impact the effectiveness of immune-based systemic cancer treatments.
See reference for more information
Adapted from Mori LC, Ramos VL. Corticosteroids for Common Palliative Care Symptoms. Palliative Care Network of Wisconsin. Fast facts and concepts #395. Internet. Accessed on April 10, 2020.