Abstract
Background
Dosing
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 16 mg twice a day. Other starting dosages reported in the literature include dexamethasone 4–8 mg orally two to three times per day, methylprednisolone 16–32 mg orally two to three times per day or prednisone 20–30 mg orally two to three times per day.
Duration of Therapy
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
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 facies/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 profiles 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. The relationship between peptic ulcer disease and steroids is controversial; in one nested case–control study it appeared correlated with concurrent nonsteroidal anti-inflammatory drug use and a cumulative dose greater than 1000 mg 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.
Summary
Steroids are recommended for use in bone pain, but the choice of dose, duration, and specific drug is largely empiric. Steroid toxicities are a concern, and the duration of treatment should be minimized to reduce the risk of adverse events.