Corticosteroids: use in pain management and palliative care

Corticosteroids: use in pain management and palliative care

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Corticosteroids have an established role as adjuvants in pain management, particularly for pain due to inflammation and oedema. They can be administered both locally (eg intralesional, intra-articular) and systemically.

Corticosteroids are important agents for relief of pain associated with space-occupying lesions, not only in the brain, spinal cord and nerves, but also in the liver and soft tissues. They are used where there may be inflammation and oedema in confined spaces (eg in intracerebral, pelvic, retroperitoneal and spinal malignant disease). They are often used as an interim measure while awaiting more definitive therapies (eg radiotherapy).

Corticosteroids usually given by the oral route for treatment of pain include dexamethasone, prednisolone and prednisone. They can be given as a single daily dose (in the morning) because they have long biological half-lives. For parenteral administration, dexamethasone can be given subcutaneously, preferably as a single morning dose or divided doses (in the morning and at midday) rather than as a continuous infusion. Intra-articular or intralesional injection of long-acting or depot corticosteroid, using local anaesthetic without adrenaline, is a potential method of pain relief in musculoskeletal disorders.

In palliative care, high doses of corticosteroids are associated with many adverse effects including loss of control of diabetes, dysphoric reactions and delirium, and proximal myopathy. The incidence of psychosis rises to 25% after 2 weeks use, and can occur when the dose is being adjusted rapidly—either up or down. Dexamethasone is not associated with significant fluid retention. The ceiling dose for dexamethasone is suggested to be 8 mg daily, with higher doses (eg 16 mg) for short periods only if there is a good reason. Children appear to be more sensitive to the adverse effects of corticosteroids.