It might come as a revelation to many, but corticosteroids are a prominent group of medications used in palliative care, which focuses on an interdisciplinary approach to treating individuals with life-threatening illnesses. The utilization of these drugs for such conditions is notably extensive. A research study from Canada focusing on ambulatory palliative care for cancer patients revealed that nearly half of the participants were prescribed corticosteroids. Of these, dexamethasone emerged as the most commonly used medication. A similar study conducted across various EU countries found that specialists in palliative care predominantly prescribed corticosteroids. Medical professionals have recognized the efficacy of steroids in enhancing the quality of life in the final stages.
Beyond their use in palliative care, corticosteroids have been effective in addressing health issues such as spinal cord compression, bowel obstruction, and increased intracranial pressure. Furthermore, they have broader indications. These steroidal compounds serve multiple functions: they can mimic the effects of nonsteroidal anti-inflammatory drugs in pain management, stimulate appetite, suppress nausea, and alleviate fatigue. However, it’s essential to note that there are limited studies confirming the efficacy of corticosteroids for these specific uses. This article sheds light on the pivotal role steroids play as an adjuvant analgesic for pain management. The insights shared here draw from the perspectives of licensed experts and empirical data collected by Melissa Vyvey, MD MPhil (Can Fam Physician. 2010 Dec).
Steroids for Pain Management
According to the WHO pain ladder, it’s crucial to comprehensively assess adjuvant pain medications to understand their characteristics when treating pain, ranging from mild to severe. In certain individuals, there may be a mix of bony and neuropathic pain, while others might experience pain of a different nature.
Corticosteroids stand out for their effectiveness in alleviating various types of pain, such as those stemming from bone metastases, visceral sources, and neuropathic origins. Not only do corticosteroids serve as potent pain relievers, but they can also be synergistically paired with opioid analgesics like oxycodone (examples include OxyContin and Roxicodone), hydrocodone (like Vicodin and Hydrocet), codeine (such as Codedrill and Aspalgin with aspirin), and morphine (Avinza and Duramorph, to name a few) to enhance pain relief. Moreover, corticosteroids present a viable alternative to opioids, delivering significant symptomatic relief alongside their pain-reducing properties.
Delving into the mechanism by which corticosteroids alleviate pain: glucocorticoids, a category of corticosteroids, hinder the formation of prostaglandins which are responsible for causing inflammation. Additionally, they reduce vascular permeability, thereby preventing tissue swelling or edema. Due to their lipophilic nature, glucocorticoids can traverse the blood-brain barrier. Research suggests that steroid receptors are located in peripheral nerves and the central nervous system. These steroids play a pivotal role in nerve plasticity, differentiation, and growth. Existing literature indicates that such medications can potentially reduce nerve activity in damaged areas, hence mitigating neuropathic pain through their action.
Dexamethasone, available under various brand names such as Dexasone, Decadronal, and Dexpak 10 Day, is a frequently prescribed steroid, especially when the objective is to significantly reduce or eliminate pain. Prednisone and prednisolone are also acknowledged as potent pain relievers. An advantage of prednisolone is its minimal risk of side effects like myopathy. On the other hand, dexamethasone leads to minimal water retention owing to its subdued mineralocorticoid activity, setting it apart from other corticosteroid medications. The efficacy of these steroids is further validated by their extended half-life, allowing for once-daily dosing. Dexamethasone dosages can range between 2 to 8 milligrams, and it can be administered orally or subcutaneously. For those with acute pain, administration can be as frequent as three times a day.
Potential Side Effects of Corticosteroids in Pain Management
Corticosteroids, while effective in managing pain, can lead to a variety of adverse reactions. To mitigate the onset of these undesirable effects, clinicians often consider reducing the dosage. Clinical research indicates that side effects typically manifest after an extended period of consistent medication usage. Consequently, it’s advised to administer corticosteroids over a short duration, ideally between 1 to 3 weeks. Within the realm of palliative care, corticosteroids may be prescribed for more extended periods, especially in cases with unfavorable prognoses, and where the potential side effects might not emerge before the patient’s passing. However, any extended corticosteroid treatment must be meticulously monitored. Regrettably, there are numerous reports indicating suboptimal management of corticosteroid therapy within palliative care settings.
In cases where side effects are mild or if the therapeutic necessity mandates the continued administration of corticosteroids, specific counteracting medications can help alleviate these side effects. If there’s an associated risk of gastric bleeding, gastroprotective agents are commonly co-prescribed with corticosteroids.
A heightened risk of gastric bleeding is observed when a patient consumes both nonsteroidal anti-inflammatory drugs and corticosteroids concurrently. Medical practitioners must exercise utmost caution and discretion when prescribing such combinations. The strategy for integrating corticosteroids with other medications requires a judicious approach.
On Discontinuing Corticosteroid Use
A treatment window of two weeks is generally considered a safe duration for steroid administration without triggering significant side effects. However, even brief exposures to corticosteroids can, in some cases, disrupt the HPA (hypothalamic-pituitary-adrenal) axis, with effects becoming apparent later on. If the therapy extends over a long period, a gradual tapering of the dosage is necessary. The exact duration of this tapering process remains variable and is tailored according to the length of the treatment. It’s essential to note, as highlighted by Ms. Vyvey, that discontinuation of steroids can intensify symptoms like terminal restlessness in patients receiving palliative care.