Steroids in Palliative Care

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Steroids in Palliative Care

• A Short Review

Edward (Ted) St. Godard MA CCFP Consultant
Physician WRHA Palliative Care
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Steroids in Palliative Care

• Pharmacology
• Common palliative symptoms
• Role of Steroids
• Common side-effects

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Steroids in Palliative Care
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Steroids in Palliative Care

• Adrenal medulla Epinephrine
• Adrenal Cortex Cortisol, aldosterone,
  dehydroepiandrosterone (DHEA)

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Steroids in Palliative Care

• Cortisol
• Glucocorticoid secreted by Zona Fasciculata
• Numerous physiological effects

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Steroids in Palliative Care
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Steroids in Palliative Care
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Steroids in Palliative Care

• Often not significantly better than other
  therapies for single symptom control (opioids for
  pain, for instance)
• Useful adjuncts in context of multiple symptoms

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Steroids in Palliative Care

• 60 PC patients Rxd steroids
• Dexamethasone, 4 16 mg/day drug of choice

Mercadante et al. The Use of Steroids in Home
Palliative Care. Support Care Cancer (2001) 9
386389
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Steroids in Palliative Care

• SBGH Jan. June 2005
• 65 patients Rxd steroids during admission
• 38 on steroids at admission
• Dexamethasone
• Pain, dyspnea, bowel obstruction, brain tumor,
  SCC

Pilkey and Daenicnk. Publication pending
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Steroids in Palliative Care

• Brain tumor
• Dexamethasone and WBRT improves performance
  status, improves neurological function
  (short-term benefit)
• No current standard dosing based on evidence
• Dexamethasone 8 mg bid (4 Qid)

Shih et al. Role of Steroids in Palliative
Care. Journal Pain and Palliative
Pharmacotherapy. 21 (4) 2007
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Steroids in Palliative Care

• Brain tumor
• Pain, delirium/dementia, N/V, SZ, motor deficits
  (all mainly due to increased ICP)
• Dexamethasone decreases capillary bed
  permeability, thus decrease peritumor edema

The use and toxicity of Steroids in Mgmt Brain
Metastasis. Support Care Cancer (2008)
1610411048
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Steroids in Palliative Care

• Malignant bowel obstruction
• N/V, pain, global distress
• Decrease peri-tumor edema
• NNT 6 Trend toward improvement
• No evidence of impact on mortality
• No dosing recommendations, SE increase with dose

Feuer et al. Systematic review and meta-analysis
of corticosteroids for malignant bowel
obstruction in advanced gynaecological and
gastrointestinal cancers. Annals of Oncology 10
1035 - 1041, 1999.
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Steroids in Palliative Care

• Malignant bowel obstruction
• Steroid (Dex 4 16 mg/d)
• Metoclopramide
• Octreotide

Mercadante et al. Aggressive Pharmacological
Treatment for Reversing Malignant Bowel
Obstruction. Journal Pain and Symptom Mgmt.
284 2004
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Steroids in Palliative Care

• Nausea, emesis
• ?reduced permeability BBB to chemicals that
  induce emesis
• Good evidence as adjuncts (with D2 antagonists,
  5-HT3 antagonists)
• Dexamethasone 4 16 mg/d

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A
B
Anorexigenic Neuropeptide
Orexigenic Neuropeptide
Anorexigenic Neuropeptide
Orexigenic Neuropeptide
Neurotensin
MCH
Neurotensin
MCH
_
_
CNS Cytokinase
Melanocortin
AGRP
Melanocortin
AGRP
CNS Cytokinase
CNTF
_
IL-1
IL-1 IL-6 TNF-? INF-?

_
_
CRF
NPY
CRF
NPY
Tryptophan

_

Seratonin
Food Intake Energy Expenditure
_
_

ACTH
Food Intake Energy Expenditure
Blood Brain Barrier
Blood Brain Barrier
Glucocorticoids


_

IL-6


Glucogon
Glucogon
Cytokinase
CNTF
IL-1
CCK
Leptin
CCK
Leptin




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A
B
Anorexigenic Neuropeptide
Orexigenic Neuropeptide
Anorexigenic Neuropeptide
Orexigenic Neuropeptide
Neurotensin
MCH
Neurotensin
MCH
_
_
CNS Cytokinase
Melanocortin
AGRP
Melanocortin
AGRP
CNS Cytokinase
CNTF
_
IL-1
IL-1 IL-6 TNF-? INF-?

_
_
CRF
NPY
CRF
NPY
Tryptophan

_

Seratonin
Food Intake Energy Expenditure
_
_

ACTH
Food Intake Energy Expenditure
Blood Brain Barrier
Blood Brain Barrier

Glucocorticoids

_

IL-6


Glucogon
Glucogon
Cytokinase
CNTF
IL-1
CCK
Leptin
CCK
Leptin




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Steroids in Palliative Care

• Anorexia
• Terribly distressing symptom (worse for families
  than patients)
• Predictive of early demise?

Matin and Jatoi. Megesterol Acetate for the
Palliatiation of Anorexia in Advance Incurable
Cancer. Clinical Nutrition. 2006. 255
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Steroids in Palliative Care

• Anorexia and cachexia
• Short-term appetite stimulation
• Comparable to Megesterol
• Lowest dose, pulse, titrate down

Matin and Jatoi. Megesterol Acetate for the
Palliatiation of Anorexia in Advance Incurable
Cancer. Clinical Nutrition. 2006. 255
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Steroids in Palliative Care

• Fatigue and depression
• Fatigue and weakness huge problem
• Pulse steroids significantly improve fatigue in
  number of patients
• Short-lived
• Side-effects (increased appetite)

Lundstrom et al. The Existential Impact of
Starting Steroids in Advanced Metastatic Cancer.
Palliative Medicine. 2009 23
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Steroids in Palliative Care

• Fatigue and depression
• Depression 15 30 cancer patients
• Optimal anti-depressants take too long
• Steroids promote sense of well-being
• Short-lived
• Side effects

Lundstrom et al. The Existential Impact of
Starting Steroids in Advanced Metastatic Cancer.
Palliative Medicine. 2009 23
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Steroids in Palliative Care

• Spinal cord compression
• Reduce edema, alleviate pain, improve neurologic
  outcomes
• Some benefit from high dose, but significantly
  increased SE
• Dexamethasone 10 mg IV, then 8 mg bid

Loblaw et al. J. Clin Oncol. 2005. 23 (30)
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Steroids in Palliative Care

• SVC syndrome
• Often useful in dyspnea 2 airway edema
• Steroids as temporizing measure
• Chronic use of course leads to SE
• Lack of robust evidence base
• Dex dose?
• Wan et al. Superior Vena Cave Syndrome.
• Emergency clinics North America. 272. 2009

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Steroids in Palliative Care

• Bone pain
• Weak evidence base
• Strong anecdotal support
• Dex 4 16 mg/d

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Steroids in Palliative Care

• Equivocal evidence STRONG DRUGS
• Potential for multiple adverse effects
• Clearly dose-related
• Many preventable
• Most reversible

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Steroids in Palliative Care
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Steroids in Palliative Care

• Hyperglycemia common
• Symptoms (polyuria, etc.)
• Susceptible to infx, neuropathy
• Monitor, treat
• Late afternoon capillary glucose

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Steroids in Palliative Care
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Steroids in Palliative Care

• Immune modulation
• Compromised patients
• Oral candidiasis Thrush
• Painful and frustrating
• Nystatin, fluconazole

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Steroids in Palliative Care

• GI bleed, gastritis
• Potentially catastrophic
• Preventable
• H2 blocker, PPI

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Steroids in Palliative Care
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Steroids in Palliative Care

• Myopathy
• Aches and pains
• Weakness
• Ambiguous
• Decrease dose or discontinue

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Steroids in Palliative Care

• Miscellaneous
• moon facies, Cushing
• Addissonianism
• Jitters, poor sleep
• Weight gain, voracious appetite
• Osteoporosis

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Steroids in Palliative Care

• Re-cap
• Multiple indications
• Variable evidence
• Good anecdotal support
• Dexamethasone PO/IV/SQ
• 4 16 mg/day
• Short term trials
• GUT PROTECTION