As palliative care (PC) moves upstream in the course of serious illness and the development of drugs and their indications rapidly expand, PC providers must understand common drug indications and adverse effects to ensure safe and effective prescribing. Pharmacists, experts in the nuances of medication management, are valuable resources and colleagues for PC providers. This article will offer PC providers 10 useful clinical pharmacy tips that PC pharmacists think all PC providers should know for safe and effective symptom management. Close collaboration with or addition of a trained pharmacist to your PC team can improve clinical care for all PC patients.
Purpose: Baseline use of corticosteroids is associated with poor outcomes in patients with non-small-cell lung cancer (NSCLC) treated with programmed cell death-1 axis inhibition. To approach the question of causation versus correlation for this association, we examined outcomes in patients treated with immunotherapy depending on whether corticosteroids were administered for cancer-related palliative reasons or cancer-unrelated indications.
Patients and methods: Clinical outcomes in patients with NSCLC treated with immunotherapy who received >= 10 mg prednisone were compared with outcomes in patients who received 0 to < 10 mg of prednisone.
RESULTS: Of 650 patients, the 93 patients (14.3%) who received >= 10 mg of prednisone at the time of immunotherapy initiation had shorter median progression-free survival (mPFS) and median overall survival (mOS) times than patients who received 0 to < 10 mg of prednisone (mPFS, 2.0 v 3.4 months, respectively; P = .01; mOS, 4.9 v 11.2 months, respectively; P < .001). When analyzed by reason for corticosteroid administration, mPFS and mOS were significantly shorter only among patients who received >= 10 mg prednisone for palliative indications compared with patients who received >= 10 mg prednisone for cancer-unrelated reasons and with patients receiving 0 to < 10 mg of prednisone (mPFS, 1.4 v 4.6 v 3.4 months, respectively; log-rank P < .001 across the three groups; mOS, 2.2 v 10.7 v 11.2 months, respectively; log-rank P < .001 across the three groups). There was no significant difference in mPFS or mOS in patients receiving >= 10 mg of prednisone for cancer-unrelated indications compared with patients receiving 0 to < 10 mg of prednisone.
CONCLUSION: Although patients with NSCLC treated with >= 10 mg of prednisone at the time of immunotherapy initiation have worse outcomes than patients who received 0 to < 10 mg of prednisone, this difference seems to be driven by a poor-prognosis subgroup of patients who receive corticosteroids for palliative indications.
This study aimed to determine the range of mean cumulative corticosteroid doses that could effectively palliate dyspnea in opioid-treated patients with terminal cancer and to investigate the demographic or biochemical factors predictive of corticosteroid responsiveness. To this end, responders and nonresponders were compared with regard to corticosteroid dose and whether they had initiated opioid use before or concomitantly with corticosteroid use. A logistic regression analysis was conducted to assess the impacts of demographic and biochemical factors on corticosteroid effectiveness. The final sample comprised 20 patients who satisfied the selection criteria. The responders accounted for 70% of the total sample (n = 14) and experienced the strongest effect with regard to dyspnea palliation at a mean cumulative dose equivalent to 64.4 mg prednisolone. However, no factors predictive of response were identified. In summary, this retrospective study identified effective corticosteroid doses for dyspnea alleviation in terminal cancer patients. Although our study sample was limited in size, the results support further prospective research.
BACKGROUND: Corticosteroids are frequently utilized in the palliative care setting to combat symptoms such as fatigue, dyspnea, pain, weakness, anorexia, cachexia, nausea, and vomiting. Often times, adverse effects arise with corticosteroid use, and it is unclear whether switching to another corticosteroid would reduce the risk of specific adverse effects or what measures can be taken to alleviate the adverse effects.
OBJECTIVE: This article aims to review the differentiating pharmacokinetics, potency, and adverse effect profiles of corticosteroids and summarize their clinical applicability.
METHODS: A literature review of "corticosteroids" and "palliative care" was performed using the PubMed database through July 2018. Original studies relevant to the purpose of this study were identified and those that met inclusion criteria were included.
RESULTS: Although corticosteroids share many common factors, including similar pharmacokinetic, pharmacodymanic, and adverse effect profiles, they have significant differences when the details of these variables are reviewed. Providers that prescribe corticosteroids for symptom management should be aware of these differences and the recommended management strategies.
CONCLUSIONS: Recognition of corticosteroid induced adverse effect profiles and possible management strategies is crucial to optimal symptom management in palliative care patients.
Introduction: Les corticoïdes sont largement prescrits en cancérologie, mais aussi en médecine palliative, à visée symptomatique. Cependant, le niveau de preuve de leur efficacité reste faible pour certaines indications. Il n’existe pas de recommandations précises concernant leur utilisation en situation palliative avancée. L’objectif de l’étude était de connaître l’utilisation de la corticothérapie par voie générale, par les médecins en unité de soins palliatifs.
Méthode: Une étude observationnelle, déclarative et descriptive a été menée, de juillet à septembre 2014, sur la base d’un questionnaire, adressé par courrier électronique à deux reprises, aux médecins des 122 unités de soins palliatifs françaises métropolitaines. L’objectif était d’observer leur utilisation des corticoïdes : indications, contre-indications, modalités de prescription, effets thérapeutiques, effets indésirables, moyens de surveillance de la corticothérapie.
Résultats: Soixante-trois médecins de 49 unités de soins palliatifs sur 122 ont répondu. Parmi les répondeurs, 63,5 % répondeurs des prescrivaient un corticoïde au minimum chez un patient sur deux et 95,2 % n’utilisaient pas de protocole. Les trois indications selon l’autorisation de mise sur le marché ou recommandées justifiant le plus souvent une prescription de corticoïde étaient : l’œdème cérébral de cause tumorale, l’occlusion intestinale et la compression abdominopelvienne. La majorité des médecins ne retenait pas l’hypertension artérielle ni le diabète comme contre-indication. La méthylprednisolone et la prednisolone étaient les deux molécules le plus couramment utilisées, majoritairement par voie orale. Le diabète cortico-induit, l’insomnie et l’hypertension artérielle étaient les trois effets indésirables le plus souvent rapportés.
Conclusion: Les modalités d’utilisation des corticoïdes par les médecins des unités de soins palliatifs françaises se rejoignent sur un certain nombre de points, souvent en adéquation avec les recommandations existantes mais de faible niveau de preuve. Des disparités de pratiques existent. Des recommandations avec un niveau de preuve plus élevé permettraient d’optimiser la prescription de corticoïdes en unité de soins palliatifs.
CONTEXT: Bone metastases are a common complication in patients with advanced cancer but little is known regarding current practice patterns of palliative care providers when prescribing corticosteroids as adjuvant therapy for painful bone metastases.
OBJECTIVE: To identify current practice patterns among palliative care providers when prescribing corticosteroids for the treatment of painful bone metastases.
METHODS: A cross-sectional, online survey of the membership of the American Academy of Hospice and Palliative Medicine. Providers were asked to report how frequently they prescribed corticosteroids as adjuvant therapy in patients with painful bone metastases, and to specify the corticosteroid, dosage, treatment duration, and the gastroprotective strategy most frequently utilized.
RESULTS: Seven hundred sixty-five participants responded to the survey and 600 (78%) of respondents completed the survey. Ninety-eight percent of respondents completing the survey reported having prescribed corticosteroids as adjuvant pain therapy, and 66% ordered corticosteroids for the majority of their patients with painful bone metastases. Dexamethasone was the most widely prescribed corticosteroid. Eight milligrams divided twice daily was the most common dosage selected and once started, it was usually continued indefinitely.
CONCLUSION: Corticosteroids are commonly prescribed as adjuvant therapy in the treatment of painful bone metastases in patients with limited life expectancy. Dexamethasone is the most commonly selected corticosteroid by American palliative care providers with variation existing among providers regarding dosing schedule, treatment duration, and gastroprotective strategies. Clinical trials comparing a total daily dose of four versus eight milligrams of dexamethasone would be clinically useful to inform evidence-based practice.
Our primary objective was to prospectively evaluate the effects of corticosteroids on dyspnea in terminal cancer patients at Kasugai Municipal Hospital using the Japanese version of the Support Team Assessment Schedule (STAS-J). Our secondary objective was to report the side effects of corticosteroid use in these patients. The prospective investigation included two female patients with terminal breast cancer (Patients 1 and 2, ages 53 and 57 years, respectively) who satisfied the consecutive selection criteria and were hospitalized at Kasugai Municipal Hospital between January 2016 and March 2017. We used both interviews and a review of clinical records to evaluate these patients’ responses to oral or intravenous corticosteroid therapy for dyspnea. Patient 1 had an initial STAS-J dyspnea scale score of 4 before the commencement of corticosteroid administration, which decreased to scores of 2 (day 1) and 1 (day 2 and day 3) after corticosteroid administration. Patient 2 had an initial STAS-J scale score of 3, which decreased to 1 on day 1 and was maintained at this level until death occurred on day 15. Both patients experienced rapid relief of dyspnea (within 24 hours), indicating that corticosteroids may be used to effectively treat early dyspnea experienced by terminal cancer patients.
Dyspnea is a common symptom in patients with cancer, particularly those with advanced disease. Although corticosteroids can provide effective symptom relief to such patients, the effects of these drugs on dyspnea have not been evaluated. Therefore, we retrospectively evaluated the effect of corticosteroids on dyspnea in patients with terminal cancer through a surrogate third-party evaluation intended to overcome the difficulties of self-evaluation. We investigated the electronic medical records of 693 patients who were hospitalized at Kasugai Municipal Hospital between January and December 2015 and subsequently died. After excluding patients whose deaths were not directly cancer-related and 214 patients remained eligible, 19 of 34 remaining patients with dyspnea were ultimately included in the survey. Eleven patients in the final sample received corticosteroid treatment. Among the 11 patients who received corticosteroids, 9 (81.8%), 1 (9.1%), and 1 (9.1%) received betamethasone, dexamethasone, and prednisolone. The expression of the intended effect was observed in 6 of 11 patients in the steroid group. The median time to effect expression in the steroid group was 2 days. The median durations of effect in the steroid group were 3 days. After eliminating the opioid effect, we confirmed that steroid administration improved patients’ STAS-J scores and possibly alleviated dyspnea.
In patients with cancer, dyspnea, which serves as a prognostic factor, increases toward the end of life. Notably, corticosteroid treatment can alleviate dyspnea in this patient population. Therefore, it is important to investigate the effects of corticosteroid responsiveness on patient survival. Accordingly, we retrospectively evaluated these effects and the efficacy of corticosteroids for dyspnea alleviation in patients with terminal cancer. Patients for whom corticosteroid therapy was or was not effective were designated as responders or non-responders, respectively, and survival was compared among patients in both groups. The primary endpoint was patient survival, and the secondary endpoints were the incidence of adverse effects and the effect of combination medicine use on responses to corticosteroids. From January 2012 through December 2015, 52 patients were investigated, and 30 and 22 were classified as responders and non-responders, respectively. Survival significantly increased among responders, compared to that among non-responders (8.5 vs. 5.0 days, P = 0.0019, Mann–Whitney U-test), although the average corticosteroid daily doses (in prednisolone equivalents) did not differ significantly (28.96 ± 12.83 and 29.13 ± 18.48 mg among responders and non-responders, respectively; P = 0.75, unpaired t-test). Observed corticosteroid-related side effects included insomnia (15.4%), delirium (11.5%), and hyperglycemia (3.8%). The authors attribute the survival difference to responsiveness to corticosteroids, as opposed to differences in patient prognosis related to underlying disease processes that resulted in apparent responses to medication. Our results suggest that further research is needed to evaluate the clinical factors related to corticosteroid combination therapy.
Dyspnea is a common symptom in patients with cancer, particularly those with late-stage terminal disease. It markedly affects terminal cancer patients, reducing their quality of life. Reduced quality of life also affects survival; therefore, dyspnea is a prognostic factor. However, the role of corticosteroids, which often are used to alleviate dyspnea, has not been sufficiently validated. In this study, we retrospectively investigated whether corticosteroid monotherapy was effective for dyspnea palliation. The effectiveness rate of corticosteroid therapy was 45% in nine male and two female study subjects (mean age: 74.5 years; range: 64–86 years). No significant differences were found between responders and nonresponders in the first-day corticosteroid doses (25.5 ± 10.86 vs. 36.1 ± 16.39 mg, P = .29) or doses administered on 2 days (47.7 ± 25.99 vs. 72.2 ± 32.78 mg, P = .25). The mean ± standard error assessment score changed significantly from 2.7 ± 0.14 at the beginning of corticosteroid administration to 1.5 ± 0.37 at the time of maximum effect (P = .028); however, the decrease to 2.1 ± 0.25 at the final administration was not significant (P = .068). This indicates that corticosteroid therapy relieved dyspnea and could provide an early-stage treatment option.
Dyspnea negatively affects the survival and quality of life of patients with terminal cancer. Although corticosteroids are currently used to treat dyspnea, the association between corticosteroid dosage and survival remains unclear. This retrospective study was conducted to determine the relationship betweencorticosteroid doses, administered to hospitalized patients with terminal cancer for dyspnea alleviation, and survival. Subsequently, we investigated the associations between corticosteroid doses, which were classified into three categories, and the length of survival in days after stratifying 52 patients treated between January 2012 and December 2015 into corticosteroid responders and non-responders. The mean daily corticosteroid doses were 28.68 ± 14.4 mg for responders and 29.13 ± 18.5 mg for non-responders. The mean corticosteroid doses on the first day were 27.86 ± 14.9 mg for responders and 27.73 ± 19.5 mg for non-responders. The mean total corticosteroid doses administered during the first 2 days of treatment were 56.84 ± 29.2 mg for responders and 57.16 ± 38.5 mg for non-responders. The mean survival was 11.33 ± 7.5 days and 5.27 ± 3.35 days among responders and non-responders, respectively. In conclusion, the administration of corticosteroid for dyspnea alleviation did not correlate with survival. However, reactivity to corticosteroids increased the duration of corticosteroid use, which may have contributed to survival.
Ce travail a pour objectif d'analyser la place du pharmacien d'officine dans le parcours des patients en soins palliatifs à domicile. Tout d'abord, l'auteur revient sur l'organisation et les définitions des soins palliatifs, puis relate l'histoire de trois patients hospitalisés dans un service de soins palliatifs, afin d'illustrer la réalité de ces soins et permettre de mieux comprendre leurs besoins au moment d'un retour au domicile. Un état des lieux sur les pharmaciens d'officine face aux soins palliatifs est analysé à l'aide d'un questionnaire. Puis l'auteur traite de la mission première du pharmacien qu'est la dispension de médicaments et du matériel médical en abordant leurs spécificités dans le contexte des soins palliatifs.
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Les patients ayant des métastases épidurales ont souvent une douleur sévère au dos. Les auteurs étudient l'utilisation d'injections de stéroïdes épidurales qui allègent la douleur du dos chez des malades cancéreux.
Cette présentation a trois objectifs : expliquer la pharmacologie et les applications cliniques des corticostéroïdes, partager les résultats d'une revue de l'utilisation de la dexaméthasone à la Maison Michel Sarrazin, réfléchir sur les différents enjeux de l'utilisation des corticostéroïdes en soisn palliatifs.
Les corticostéroïdes sont largement utilisés en soins palliatifs pour diverses raisons. Bien que les bénéfices soient nombreux, les effets secondaires sont fréquents et l'utilisation des corticostéroïdes doit donc être judicieuse. Une analyse des dossiers de patients a été faite dans une unité de soins palliatifs au Canada afin d'étudier de manière qualitative et quantitative l'utilisation des corticostéroïdes.
Dans cet article, l'auteur se penche sur les traitements proposés pour soigner les tumeurs et les occlusions intestinales. Une occlusion s'avère être, en effet, une source de symptômes gênant pour le patient et sa famille dont les plus difficiles à contrôler sont les nausées et les vomissements.
Cet article concerne d'abord le traitement palliatif des bronchites chroniques obstructives et de l'emphysème. Le contrôle médical comporte l'évaluation de la capacité expiratoire, l'arrêt du tabagisme, l'antibiothérapie lors des complications infectieuses, les bronchodilatateurs et les corticoïdes. L'auteur aborde ensuite les questions de l'oxygénothérapie à long terme et des programmes de réhabilitation multidisciplnaires. D'autres pathologies pulmonaires graves sont plus rares : asthme , bronchectasie, fibrose cystique, fibrose pulmonaire. Le symptôme de dyspnée est traité pour ses répercussions psychosociales, les thérapeutiques médicamenteuses et le soulagement du patient en phase terminale. Cet ensemble replace le problème des maladies pulmonaires chroniques dans le cadre de la nécessité d'une prise en charge globale selon la démarche palliative.