HomeThe adjuvant analgesics or co-analgesic drugs are not true analgesics in the pharmacological sense but may contribute substantially to pain relief when used either alone or in combination with analgesics. They can have an analgesic-sparing effect and should be considered in the treatment of all types of cancer-related pain. They are of particular use for opioid-insensitive pain, including neuropathic pain. Action-Corticosteroids inhibit prostaglandin production with reduction of inflammation and oedema associated with tumour deposits. They also have a central action, evidenced by their effect on mood and appetite. In patients with lymphoproliferative disorders, and a few with breast and prostate cancers, there is also an antitumour effect. Indications-Corticosteroids are particularly useful for pain related to raised intracranial pressure, extradural spinal cord compression and tumour compression and invasion of nerve roots or individual peripheral nerves. Corticosteroids are effective in treating the pain of bone metastases and that due to capsular stretching by metastases in the liver and other viscera. Pain associated with vena caval obstruction and lymphoedema may be reduced by the use of corticosteroids. The generalised bone and endosteal pain associated with haematological malignancies, as well as the pain related to hepato-splenomegaly or lymphadenopathy, frequently respond to corticosteroids. Contraindications-There are no absolute contraindications to corticosteroid therapy, but the presence or severity of some side effects may limit the dose. Preparations-The commonly used corticosteroid preparations are prednisolone, dexamethasone and hydrocortisone. Choice of preparation-If parenteral therapy is required, dexamethasone is cheaper than hydrocortisone and has less mineralocorticoid side effects. If continued oral therapy is anticipated, especially at moderate or high dosage, dexamethasone is preferable to prednisolone because of the lesser mineralocorticoid effects. Dose-Acute neurological problems, including spinal cord compression and raised intracranial pressure, are treated with dexamethasone 16-24 mg/day. The dose is weaned as soon as clinically feasible. For other indications, dexamethasone 2-4 mg/d or prednisolone 15-30 mg/d are frequently effective; however treatment can be initiated at a higher dose, in order not to miss a treatment effect, and the dose then weaned. At such time as patients taking corticosteroids lose the ability to swallow, consideration can be given as to the need to continue treatment. Dexamethasone can be mixed with morphine for SC infusion providing this is done at body temperature and not room temperature; others recommend dexamethasone be given as a separate infusion. Side effects-The side effects of corticosteroids relate to both the dose employed and the duration of treatment. For patients with cancer, the clinical importance of these side effects depends on their life expectancy. Patients taking corticosteroids for more than a few weeks will develop a Cushingoid facies and body habitus, to some degree, depending on the dose. Oropharyngeal candidiasis is common. Dyspepsia occurs relatively frequently, particularly in patients also receiving aspirin or NSAID, and treatment with antacids, an H2-receptor antagonist or misoprostol may be considered. There may be subjective improvement in muscle strength, which is often transient. Chronic administration of corticosteroids leads to proximal myopathy and weakness which can be debilitating. The production or aggravation of diabetes may require therapy. Fluid retention and oedema may occur with high doses. Abrupt withdrawal of steroids can produce hypoadrenalism and some patients suffer severe arthralgia. The neuropsychological side effects of corticosteroids are variable. There is frequently an improved sense of well-being, although many patients suffer insomnia. Less frequently, patients develop more serious side effects including frank psychosis.*59\55\2*
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