Fast Facts and Concept #129: Steroids in the Treatment of Bone Pain

Authors: Elizabeth Weinstein and Bob Arnold

Corticosteroids are recommended as an adjuvant analgesic for cancer-related bone pain. The mechanism of action is unclear, but may be related to decreasing peritumoral edema or inhibition of prostaglandin and leukotriene synthesis. 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 16mg po bid. 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 20-30mg po 2-3 times per day.

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 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 faces/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.

While 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 1000mg 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.

In summary, steroids are recommended for use in bone pain, but the choice of dose, duration and specific drug is entirely empiric. Steroid toxicities are a concern; the duration of treatment should be minimized to reduce the risk of adverse events.

Resources

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7. Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid Use and Peptic Ulcer Disease: Role of Nonsteroidal Anti-Inflammatory Drugs. Annals Intern Med 1991; 114:735-740.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Wientstein E and Arnold B . Fast Facts and Concepts #129: Steroids in the treatment of bone pain. January 2005. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information; this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in 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.

Creation Date: 1/2005

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>non-opioids; cancer

Specific Disease and Organ System Category(s): Cancer