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Palliative cancer care - nausea & vomiting - Management
What issues do I need to be aware of before prescribing dexamethasone?
- Dexamethasone is generally given as a single dose in the morning but may be given via a syringe driver when appropriate. If large doses cannot be taken at once because of nausea, the dose may be divided and given in the morning and at lunchtime. If possible, oral or subcutaneous dexamethasone should be taken no later than 16.00 hours, to avoid night-time restlessness.
- Regular mouth care is essential in people taking oral corticosteroids because oral candidiasis is common.
- Dyspepsia and indigestion are common. The risk of serious gastrointestinal complications (e.g. peptic ulcer or silent perforation) is markedly increased in people who are also taking nonsteroidal anti-inflammatory drugs (NSAIDs) [Piper et al, 1991]. Gastrointestinal prophylaxis with a proton pump inhibitor or misoprostol should be considered for people receiving concurrent NSAIDs or those with a history of peptic ulcer disease. Use dexamethasone in people with active peptic ulcer disease only if the benefits are likely to outweigh the risks.
- Corticosteroids may worsen diabetic control.
- Advise all people using corticosteroids to seek urgent medical attention if they come into contact with someone with chickenpox or shingles [CSM, 1998].
- Stopping use of dexamethasone in the terminal phase lacks expert consensus:
- If the oral route is no longer available, dexamethasone can be given as a single slow subcutaneous dose once a day.
- If treatment is not given, patients may become agitated and distressed because of corticosteroid withdrawal. The onset of withdrawal symptoms is highly variable, depending on the risk of adrenal suppression, the length of time that the person lives after their last treatment, and their degree of physical stress; it is highly unlikely within the first 24 hours.
- The clinician must balance the disadvantages of intrusive treatment of a dying person against the risks of not providing treatment.
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