Steroid Prescribing in Palliative Care: Key Messages
Following several serious incidents relating to prescriptions of Dexamethasone in the trust, please find below some key practice points:
- Steroids may be used in palliative care for symptom control
- Dexamethasone is usual steroid of choice in palliative care.
- Dexamethasone 6mg is equivalent to Prednisolone 42mg (6mg x7) orally.
- Most indications are “off label” and potentially have serious side effects g.
- diabetes mellitus,
- increased susceptibility to infections
- significant myopathies
- Always document in/on the medical notes, drug chart and EDN
- indication for steroids
- plan for review or down titration.
- Keep to short courses and lowest effective dose.
- Review after 5 days when starting steroids if no benefit, stop.
- If benefit, reduce to the lowest dose that sustains benefit and plan for on-going review.
- Limit course of steroids to < 3 weeks, where possible, as can be tapered fairly quickly within this duration;
- Longer courses > 3weeks will require slower and more prolonged tapering.
- Consider a PPI for the duration of steroid course, review need for PPI when steroids stop
- Clear plan
- Do not discharge patients on steroids without a clear plan
- Patients on high dose steroids will need clear instructions for reduction
- Discharge letters should always provide
- plan for steroid reduction/ review
- clear designation of who is responsible
- time frame for when this should take place
When commencing steroids in hospital or in the community
- Measure a baseline blood glucose in patient not known to have diabetes or diet control diabetes
- If blood glucose <11.1mmols they should be educated on the risk of steroid induced hyperglycaemia and possible symptoms discussed (tiredness, fatigue, thirst, dry mouth, frequent need to pass large volumes of urine, genital thrush, blurred vision)
- If they experience these symptoms they will need to be given a blood glucose machine and to monitor once daily pre evening meal as blood glucose tend to run high during the day and reverts to single figures the next morning
- If blood glucose >11.1 mmols patient should be given a home blood glucose monitor to test for steroid induced hyperglycaemia and same guidance above re symptoms
- For known diabetics on oral hypoglycaemic agents (OHAs) and/or insulin who are already monitoring their blood glucose at home need to be informed of steroid induced hyperglycaemia and need to monitor more closely pre meal and pre bed
We would be aiming for diabetic control 6 to 16 mmols
- If blood glucose levels run >16mmols for more than two occasions in a 24-hour period in any of these groups of patients then start or increase diabetes medication
- Steroid-induced hyperglycaemia is usually treated with gliclazide tablets or insulin injections
Recommended Dexamethasone starting doses are as follows:
- Malignant Spinal Cord Compression
- Raised Intracranial Pressure (i.e. brain mets)
16mg OD if severe
8mg OD if mild-mod symptoms
- Liver capsule pain
- Appetite/ fatigue
- Nausea & vomiting (not related to chemo)
- Bowel obstruction
6mg OD subcut
- Airway obstruction/ SVCO (whilst seeking specialist advice regarding investigation and definitive management)