Steroids Reduce inflammation around the tunour & cord oedema Reduce pain Preserve neurological function Increase number of patients who remain ambulatory High dose initially Reduce rapidly Where good results possible to stop steroid treatment completely
Choice and dose of steroid Use dexamethasone Dose is 16mg per day divided into 2 doses (N.B.= approx 100mg prednisolone) Trials compared 16mg per day with 96mg per day showed more side-effects with higher dose Give after Breakfast and Lunch. Reduce dose over 2 weeks can cause problems if stopped suddenly. If symptoms worsen increase dose/reduce more slowly. Some patients may be on maintenance steroids.
WPH Reducing regimen DayDexamethasone daily dose Administration 1-316mg16mg OM or 8mg BD (8am & 12noon) 4-68mg8mg OM 7-94mg4md OM 10-122mg2mg OM 13Discontinue
Adverse Effects Gastric irritation Take after food. PPI cover Lansoprazole 15mg OD Only for the duration of the steroids. Increased Appetite Impaired glucose tolerance Mood disturbances Fluid retention
Long-term adverse effects Osteoporosis Muscle weakness Reduced healing/ability to fight infection Care around people with chicken pox/ measles/influenza Glaucoma Impaired healing “Cushing’s Syndrome”……
Points to remember Take steroids with or after food Avoid take steroids later than 4pm Dexamethasone can be dispersed in water & given via PEG/NG (off license) Dexamethasone liquid is available If the patient has had other courses of steroids in the last year they may need to reduce the dose more slowly Avoid contact with anyone with suspected chicken pox or shingles. Check the patient understands how to reduce their dose.
Thromboprophylaxis Active Cancer Reduced Mobility Inpatient hospital stay = VTE Risk Prescribe thromboprophylaxis unless contra-indicated. Consider if thromboprophylaxis is indicated on discharge – immobility?
Laxatives Constipation often associated with mSCC Can be one of the presenting symptoms Maintaining regular bowel action is important for patient comfort Psychological issues also need to be overcome e.g. patients embarrassment at needing to be assisted with toileting
Laxatives Oral laxatives may be ineffective or inappropriate Reflex bowel Patient has little/no awareness of bowel fulness Reflex function of the rectum remains Fast acting rectal measures most appropriate Bisacodyl suppositories or sodium citrate enemas (15- 30mins to effect) If hard stools, glycerol suppository Flaccid bowel May need digital removal No laxatives recommended
Pain Control Analgesia WHO Pain ladder NICE neuropathic pain guidance Bone Pain Zoledronic Acid (IV) Check Renal function Denosumab (SC) Licensed for prevention of skeletal events