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Table 1 - Good Prescribing Practice for Corticosteroids – see more information on NHS Lothian Steroid Safety Bundle
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1
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Document indication for the corticosteroid on the patient’s notes.
Baseline HbA1C should be taken. If known diabetic or HbA1c >/= 42, follow guidance in Lothian Steroid Safety Bundle (link above)
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2
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Steroids have long half-life so can be prescribed once a day after breakfast. If the patient prefers to have the dose split, then do not give after 14.00. Dexamethasone comes in 2mg and 0.5mg (500microgram) tablets.
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3
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Start gastric protection with a PPI (e.g. omeprazole 20mg od).
Note PPI increase risk of C Difficile and can cause hyponatraemia (if sodium drops swap PPI to famotidine) and stomatitis, so should be stopped 7 days after steroids (if no on-going GI symptoms)
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4
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Ensure appropriate patient information regarding corticosteroids (importance of not stopping suddenly, dietary advice) and dose reduction regimen on discharge. Counsel if necessary.
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5
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All patients should be given a STEROID EMERGENCY CARD and advised of ‘sick day rules’ - if have fever, infection needing antibiotics, undergoing surgical procedure etc
- If taking 0.5-1.0mg Dexamethasone, double this dose whilst unwell or on day of procedure.
- If taking 1.5mg Dexamethasone or higher – stay on same dose
If vomiting and unable to take steroids should attend hospital for IV/IM steroids
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6
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Monitor all patients on high dose steroids for:
- Diabetes (NB sugars peak late afternoon) see Steroid Safety bundle for guidance on management of steroid induced diabetes
- Dyspepsia/ epigastric pain
- Mania/hypomania/psychosis
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7
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If taking 2mg or more dexamethasone for more than 3 months and patient has a reasonable prognosis consider oral bisphosphonates +/- vitamin D & calcium for prevention of osteoporosis
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8
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Consideration of Co-trimoxazole prophylaxis if patient has significant immunocompromise or co-existing respiratory conditions. See more information here
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- The steroid dose should be reviewed regularly, and if possible, reduced. This can be undertaken by oncologists, nurse specialists, palliative care team or GPs.
- The speed of reduction will depend on interventions used (e.g. discontinuing after complete resection, or radiotherapy for radiosensitive tumour).
- In general, they should be reduced by around 25% every one to two weeks to the lowest level at which the patient remains well.
- It takes at least three days for the impact of reduced steroids to have an impact so symptoms within this period may not be related to steroid reduction.
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Table 2: Examples of reducing course – speed depends on individual’s symptoms
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Week
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Mild Presentation
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Moderate Presentation
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Severe Presentation
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1
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4mg od
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8mg od
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8mg bd
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2
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3mg od
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6mg od
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6mg bd
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3
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2mg od
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4mg od
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4mg bd
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4
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1.5mg od
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3mg od
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6mg od
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5
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1mg od
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2mg od
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4mg od
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6
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0.5mg od
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1.5mg od
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3mg od
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7
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Stop*
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1mg od
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2mg od
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8
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0.5mg od
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1.5mg od
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9
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Stop*
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1mg od
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10
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|
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0.5mg od
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11
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|
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Stop*
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If the patient struggles to come off steroids due to withdrawal symptoms (fatigue, aches and pains) options include:
- Alternate day dexamethasone 0.5mg alt day for two weeks.
- Conversion to prednisolone (1mg dexamethasone = 7mg prednisolone)
- Synacthen test – liaise with endocrinology.
Acute Oncology Guidelines
