Author(s): Elizabeth Weinstein and Robert Arnold MD
Background Corticosteroids are recommended as an adjuvant analgesic for cancer-related bone pain. The mechanism of action is unclear, but may be related to decreasing tumor-related edema or inhibition of prostaglandin and leukotriene synthesis. This Fast Fact discusses the use of corticosteroids for painful bone metastases; see also Fast Facts #66, 67, and #116 about palliative radiotherapy.
Dosing The ideal corticosteroid, dose, and duration of therapy for bone pain is unknown; current practice is derived from expert opinion and anecdotal case series. One randomized controlled trial demonstrated a decrease in pain scores in patients with cancer-related pain using oral methylprednisolone 16 mg PO twice a day. Other starting dosages reported in the literature include dexamethasone 4-8 mg PO 2-3 times per day, methylprednisolone 16-32mg PO 2-3 times per day or prednisone 20-30 mg PO 2-3 times per day.
Duration of Therapy The optimal duration of steroid therapy is unknown. If no benefit is seen within 5-7 days the drug should be discontinued. If beneficial, the drug should be tapered to the lowest effective dose or, if possible, discontinued to avoid long-term adverse effects.
Side Effects Side effects account for discontinuation of steroids in 5% of patients. Acute side effects include thrush (~30%), edema (20%), dyspepsia and peptic ulcer diseases, psychiatric symptoms (insomnia, delirium and anxiety), and glucose intolerance. Delayed side effects from long term use include adrenal suppression, moon facies/fat redistribution, increased susceptibility to infection, osteoporosis, skin fragility and impaired wound healing. A prospective review of 373 inpatients with advanced malignant disease demonstrated that the side effect profile of dexamethasone and prednisone are similar, although at equipotent doses dexamethasone causes slightly more thrush and psychiatric symptoms and less edema, weight gain and dyspepsia. The relationship between peptic ulcer disease and steroids is controversial; in one nested case-control study it appeared correlated with concurrent NSAID use and a cumulative dose greater than 1000 mg of prednisolone or 140 mg of dexamethasone. Case reports and prospective series suggest that psychiatric symptoms are most commonly seen in middle-aged women, are directly related to dosage, and usually resolve with dose reduction.
Summary Steroids are recommended for use in bone pain, but the choice of dose, duration and specific drug is largely empiric. Steroid toxicities are a concern; the duration of treatment should be minimized to reduce the risk of adverse events.
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Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: firstname.lastname@example.org. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.
Version History: This Fast Fact was originally edited by David E Weissman MD and published in January 2005. Current version re-copy-edited in April 2009.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weinstein D, Arnold R. Steroids in the Treatment of Bone Pain. Fast Facts and Concepts. January 2005; 129. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_129.htm.
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): Pain – Non-Opioids