How are steroids like Dexamethasone helpful for treating a patient with cancer-related pain?

1.

Elsevier ClinicalKey Clinical Overview

Treatment A low-dose steroid (usually prednisone) is prescribed concurrently with abiraterone acetate, docetaxel, mitoxantrone, and cabazitaxel Dexamethasone Used as a premedication for chemotherapy Sometimes used independently in mCRPC to lower PSA level and palliate symptoms but is not associated with survival benefit Also commonly used for palliation of bone pain, improvement in energy, and appetite stimulation

Treatment Pain Numerous pain medications (eg, acetaminophen, NSAIDs, opiates, topical therapies) can be helpful for pain Dexamethasone may be helpful for bone pain and is frequently prescribed for this indication, though high-quality evidence of efficacy is lacking It is reasonable to work with palliative care or pain management teams for difficult-to-manage pain Appetite Appetite stimulants (eg, mirtazapine, megestrol, short-term steroids) can be considered Energy Short-term use of agents such as dexamethasone can be considered to improve energy and reduce fatigue symptoms but potential risks are associated with use Osteopenia Bone-targeted therapy may be beneficial for either secondary prevention of osteoporosis, skeletal-related events, or patients with mCRPC with bone metastases Recommend calcium and vitamin D supplementation for bone health maintenance during ADT

2.

Jones, Robin L. (2024). In Goldman-Cecil Medicine (pp. 1387). DOI: 10.1016/B978-0-323-93038-3.00187-8

Pathologic fractures or lesions at imminent risk of fracture are generally treated with surgical fixation. High-risk asymptomatic metastases also may benefit from prophylactic radiation therapy.Painful lesions with no risk of fracture are treated with external-beam radiation. Dexamethasone (two 4-mg dexamethasone tablets at least 1hour before the start of radiation treatment and then every day for 4 days after radiotherapy) can reduce the risk of a radiation-associated flare of pain. Systemic palliative therapy for bone metastasesshould follow standard guidelines for the specific tumor type, and treatment can include bisphosphonates (Chapter 225), denosumab, and endocrine and/or chemotherapy.

3.

Mellinghoff, Ingo K., DeAngelis, Lisa M. (2024). In Goldman-Cecil Medicine (pp. 1310). DOI: 10.1016/B978-0-323-93038-3.00175-1

Epidural metastases require immediate treatment because patients can develop acute and unpredictable neurologic deterioration resulting in paraplegia.Patients should be started on high-dose corticosteroids (usually >20mg of intravenous dexamethasone), which rapidly relieve pain and may contribute to neurologic recovery.Surgery followed by postoperative radiation therapy is superior to radiation therapy alone for preserving the ability to walk and may prolong survival in a wide population of patients with metastatic spinal cord compression. However, it may not benefit patients who are age 65 years and older.Stereotactic radiosurgery is also an effective option to treat epidural metastases, either initially or at the time of relapse.It is much easier to preserve neurologic function than to reverse impairment, so clinically silent areas of extradural tumor that are detected on MRI should be treated before neurologic compromise develops. Patients with epidural metastasis can have a good neurologic outcome if they are treated before the onset of severe neurologic compromise, but their overall survival is usually short because of the presence of widespread metastatic disease.Patients whose primary tumor arises in the spine, such as an osteogenic sarcoma (Chapter 187), should undergo definitive surgery. The need for postoperative radiation therapy is based on the tumor’s histology.

4.

Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F. Annals of Oncology : Official Journal of the European Society for Medical Oncology. 2012;23 Suppl 7:vii139-54. doi:10.1093/annonc/mds233.

Publish date: October 1, 2012.

Patients with neurologic deficits have a poor prognosis, thus early clinical and MRI diagnosis and prompt therapy are powerful predictors of outcome in MSCC [ Steroids should be given immediately when the clinical-radiological diagnosis of MSCC is obtained. Dexamethasone is the most frequently used drug, with doses ranging from moderate (16 mg/day) to high (36–96 mg/day) eventually preceded by a bolus of 10–100 mg intravenously. The steroids are usually tapered over 2 weeks. Although no study has been published comparing high-dose to moderate dexamethasone dose, 16 mg/day remains the more often used prescription [ MSCC can be treated with surgery followed by RT or RT alone. RT is the first line treatment for the majority of patients with MSCC; it provides back pain relief in 50%–58% of cases with an interesting rate of pain disappearing (30%–35% of cases) [], hypofractionated RT regimen can be considered the approach of choice, while more protracted RT regimens (e.g. 5 × 4, 10 × 3 Gy) can be used in selected MSCC patients with a long life expectancy. On the basis of the published evidence, it can be concluded that surgery should be considered for a carefully selected group of patients, i.e. with single-level MSCC and neurological deficits. Other possible indications for surgery include the necessity of stabilization, vertebral body collapse causing bone impingement on the cord or nerve root, compression recurring after RT and an unknown primary requiring histological confirmation for diagnosis []: the results showed only a small beneficial effect on pain control in the short and medium term (1–6 months), with no modification of the analgesics used. Few RCTs, involving small numbers, have shown that isotopes can relieve bone pain in patients with breast cancer and lung cancer, while they produced inconsistent results in patients with hormone refractory prostate cancer [ Early diagnosis and prompt therapy are powerful predictors of outcome in MSCC [I, A]. The majority of patients with MSCC should receive RT alone and surgery should be reserved only for selected cases [II, B].

5.

Food and Drug Administration (DailyMed).

Publish date: November 3, 2020.

Dosage And Administration For palliative management of patients with recurrent or inoperable brain tumors, maintenance therapy with two mg two or three times a day may be effective. Acute Allergic Disorders In acute, self-limited allergic disorders or acute exacerbations of chronic allergic disorders, the following dosage schedule combining parenteral and oral therapy is suggested: Dexamethasone sodium phosphate injection, USP 4 mg/mL; first day, 1 or 2 mL (4 or 8 mg), intramuscularly. Dexamethasone sodium phosphate tablets, 0.75 mg; second and third days, 4 tablets in two divided doses each day; fourth day, 2 tablets in two divided doses; fifth and sixth days, 1 tablet each day; seventh day, no treatment; eighth day, follow-up visit. This schedule is designed to ensure adequate therapy during acute episodes, while minimizing the risk of overdosage in chronic cases. B. Intra-Articular, Intralesional and Soft Tissue Injection: Intra-articular, intralesional and soft tissue injections are generally employed when affected joints or areas are limited to one or two sites. Dosage and frequency of injection varies depending on the condition and the site of injection. The usual dose is from 0.2 to 6 mg. The frequency usually ranges from once every three to five days to once every two to three weeks. Frequent intra-articular injection may result in damage to joint tissues. Some of the usual single doses are: Site of Injection Amount of Dexamethasone Phosphate (mg) Large joints (e.g., Knee) 2 to 4 Small joints (e.g., Interphalangeal, Temporomandibular) 0.8 to 1 Bursae 2 to 3 Tendon sheaths 0.4 to 1 Soft tissue infiltration 2 to 6 Ganglia 1 to 2 Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever the solution and container permit. Dexamethasone sodium phosphate injection, USP is particularly recommended for use in conjunction with one of the less soluble, longer-acting steroids for intra-articular and soft tissue injection.