Hardy JR, Rees E, Ling J, Burman R, Feuer D, Broadley K, Stone P. Palliative Medicine 2001; 15:3-8.

Prepared by: : Dr. Robin Fainsinger

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

One hundred and six consecutive patients started on glucocorticosteroids (steroids) according to a defined prescription policy were surveyed each week to document the indications for use, any beneficial effect, any toxicity incurred and the reason for stopping. All patients had advanced malignant disease and survived for a median of 40.5 days (range 1-398 + days) from the start of steroid treatment. Fifty-seven per cent of patients completed three or more assessments. The most common specific indications for starting steroids were spinal cord compression, cerebral metastases, lymphangitis carcinomatosis and intestinal obstruction. The most common non-specific indications were anorexia, nausea, low mood, pain and vomiting. The median duration of steroid use was 21.5 days (range 1-89 days). The most common reason for the discontinuation of steroids was death or deteriorating condition. Symptom scores improved at some stage for the majority of patients started on steroids for anorexia, nausea, pain, low mood, vomiting and weakness but not in patients complaining of dyspnea or poor mobility. The most common side-effects that were most probably attributable to steroid therapy were oral candidiasis and proximal myopathy. The benefits of steroids when used according to defined guidelines were thought to outweigh toxicity.

Comments:

Strengths/uniqueness:
This study is a good attempt to apply standard prescription guidelines for corticosteroid use in palliative care patients, and report the indications for, and outcomes of this management.

Weaknesses:
The research methodology is weak due to the uncontrolled, unblinded assessments, and the inability to control for other simultaneous treatment. The use of a four point initial scale and descriptive follow-up assessment could have been improved with a ten point scale allowing a wider range of responses.

Relevance to Palliative Care:
All palliative care programs would be well served by a similar disciplined use of guidelines on corticosteroid use, as well as intermittent surveys to document practice. Better designed studies of all indications for corticosteroid use are needed.

Pharmacokinetics of High-dose Oral and Intravenous DexamethasoneDownloadable PDF File

Toth GG, Kloosterman C, Uges DRA, Jonkman MF. Therapeutic Drug Monitoring 1999; 21:532-535.

Prepared by: : Monique Bielech, Pharmacist

Received during: Journal Club (6th June 2006), Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

Pharmacokinetics of intravenous and oral pulsed high-dose dexamethasone were studied in four patients with pemphigus vulgaris. Doses for dexamethasone were varied from 100 to 300 mg. Serum concentrations were measured by high-performance liquid chromatographic procedure with diode assay detection. Bioavailability was assessed by comparing the areas under the serum concentration-time curves following oral administration with those of intravenous administration. Mean bioavailability of high-dose oral dexamethasone was 63.4%. Side effects were minor and were limited to temporary facial flushing both after oral and intravenous administration. Oral administration of dexamethasone in pemphigus patients showed to be more convenient and cost effective than administration by the intravenous route.

Comments:

Strengths/uniqueness:
This study adds to our very scant knowledge of the kinetics of dexamethasone

Weakness:
The data were collected from only pemphigus patients who were relatively young, from very few patients.

Relevance to Palliative Care:
It is a stretch to extrapolate this kinetic data to our population of patients and to our very common practice of administering this medication subcutaneously. There seems to be little danger in using a larger daily dose. The noted side effect of sleep disturbance is well-known in the palliative care literature. The clinical efficacy remains to be elucidated and will be difficult considering the many clinical indications for this drug.