8th January 2024

Steroids

Corticosteroids are used for a number of symptoms in the treatment of cancer. Glucocorticoid steroids have greater anti-inflammatory properties. By reducing oedema at the site of the tumour, they play an important role in cancer pain management. The evidence for their usefulness is based on clinician experience rather than extensive trial data. In practice, they are widely used for a number of different pain syndromes:

• Nociceptive pain: cancer can exist in enclosed spaces. In hepatomegaly, the liver capsule may stretch and cause pain. The anti-inflammatory effect can reduce this stretching and give pain relief.
• Neuropathic pain: reducing inflammation can improve ongoing compression or injury to the nerve from the malignancy – for instance, in spinal cord compression.
• Bone pain: dexamethasone is often used in treatment of metastatic bone pain to prevent worsening during radiotherapy treatment.
• Obstruction: reducing the inflammation from a malignant bowel obstruction, for instance, can increase the size of the bowel lumen and alleviate symptoms and pain.

Side effects

The utility of steroids is balanced against their many side effects. Courses of steroids may be given in short ‘pulses’ to avoid developing these. Below is by no means an exhaustive list, and a more thorough discussion of steroid side effects can be found elsewhere. However, some important things to bear in mind include:

• An increase in blood sugars is seen. Blood sugars should be checked regularly and at least daily if in a healthcare setting. In pre-existing diabetics, control may be worsened.
• Steroids are associated with an increase in adverse gastrointestinal events, including ulceration and GI bleeding. A proton pump inhibitor should be started alongside higher doses of steroids as such.
• Psychiatric disturbances, ranging from depression to paranoia, are possible. The steroid should be stopped to resolve this.
• Steroids are immunosuppressants, so long-term use may be associated with opportunistic infections.
• Avascular necrosis of bone can cause pain and loss of function within the affected area.
• Osteoporosis may cause pathological fractures, affecting pain and function. Bone protection strategies should be considered in those on long-term steroids.
• Recurrent or long doses must not be stopped abruptly due to the risk of hypoadrenalism.