Rationalising corticosteroids used for symptom or complication management in palliative care
Corticosteroids are used to manage a range of symptoms and complications in patients with palliative care needs. Dexamethasone is most commonly used because it is potent, has a long duration of action (allowing once-daily dosing) and minimal mineralocorticoid activity, and the parenteral formulation can be administered subcutaneously.
To minimise adverse effects of corticosteroids (eg insomnia, hyperglycaemia, gastric irritation, mental disturbances, increased susceptibility to infection, Cushingoid features, myopathy), use the lowest effective dose for the shortest period of time. Adverse effects of corticosteroids are generally dose and duration related; however, individuals vary in response, and adverse effects can occur at any time.
Make an individualised plan for dose reduction or stopping corticosteroid therapy at the time of prescribing. There is limited clinical evidence to support any particular approach to corticosteroid withdrawal, including tapering regimens. The approach will depend on the indication, dose and duration of therapy, the number and recency of other corticosteroid courses, drug interactions, and practical considerations (eg available tablet strengths). The plan must balance the risk of withdrawal effects (eg adrenal insufficiency or crisis) in fast tapering with a slow withdrawal that extends the exposure to and burden of therapy. A suggested approach to stopping dexamethasone is given in Suggested approach to stopping dexamethasone in patients with palliative care needs. Follow the principles of medication rationalisation when rationalising corticosteroids in palliative care.
Dexamethasone can be stopped abruptly (without tapering) if it is used for 2 weeks or less.
To reduce the risk of adrenal insufficiency, gradual withdrawal of dexamethasone is recommended when treatment is longer than 2 weeks.
If gradual withdrawal of dexamethasone is necessary, plan a dose-reduction regimen; examples include:
- For a patient taking a high dose (eg 8 mg daily) for a relatively short time (eg 6 weeks), Decrease dose by 2 mg daily every 5 to 7 days, until reaching 2 mg daily, then decrease the dose by 0.5 mg daily every 5 to 7 days to stop.
- For a patient taking a low dose (eg 2 mg daily) for a long time (eg a year), decrease by 0.5 mg daily every 14 days to stop.
Monitor patient response; if symptoms recur, consider increasing dexamethasone dose to previously tolerated dose. Once symptoms have stabilised, consider reattempting withdrawal. In some patients, stopping dexamethasone completely may not be possible; reducing to the lowest tolerated dose may be the most appropriate approach.