Can “Steroid Switching” Improve Steroid-Induced Psychosis in a Patient with Advanced Cancer?

Do Patients Benefit from a Trial of Corticosteroids at the End of Life?

OPINION STATEMENT

Patients with advanced cancer in the last 6 months of their lives have a higher frequency of distressing and debilitating physical and psychosocial symptoms such as cancer pain, cancer-related fatigue (CRF), anorexia, shortness of breath, poor sleep, anxiety, and depression. Often these symptoms significantly impact the patients' quality of life, and therefore require prompt assessment and effective treatment. There are specific treatments for certain distressing cancer-related symptoms (e.g., opioids for pain), but for the other symptoms such as CRF, anorexia-cachexia, and shortness of breath, there are limited or no evidence-based treatments. Also, in the management of cancer pain in this population, many patients are refractory to opioids. Hence, corticosteroids are one of the most common adjuvant medications prescribed for the management of this distressing symptom. However, there is limited evidence in regard to the effectiveness of corticosteroids in the improvement of the symptoms, side-effect profile, most optimal duration of use, dose, type of steroid, and most recently, the use with immunotherapy in advanced cancer patients at the end of life. These factors significantly limit the use of this important medication in terminally ill cancer patients. Further research is therefore critical to provide the optimal prescription of corticosteroids in this highly distressed population.

Psycho-Behavioural Changes in Dogs Treated with Corticosteroids: A Clinical Behaviour Perspective

Simple Summary

Corticosteroids hormones are central to stress responses and, along with other hormones and neurotransmitters, contribute to the onset of physiological and behavioural changes aimed at helping the animal cope with anticipated demand. Both the human and animal literature suggest that exposure to systemic exogenous corticosteroid treatments can be associated with negative emotional states. In this paper, the potential behavioural effects of exogenous corticosteroid treatment on dogs and other species are discussed to show why consideration should be given to this matter when prescribing these drugs.

Abstract

Arousal and distress are often important factors in problematic behaviours, and endogenous corticosteroids are important mediators in the associated stress responses. Exogenous corticosteroid treatments have been reported to change behaviour in human patients and laboratory animals, with similar changes also noted in pet dogs. These behaviours not only potentially adversely impact the welfare of the dogs, but also the quality of life of their owners. Indeed, corticosteroids can bias sensitivity towards aversion in dogs. A decrease in behaviours associated with positive affective states, such as play and exploratory behaviours, together with an increase in aggression and barking have also been described in dogs. According to the available literature, human patients with pre-existing psychiatric disorders are more at risk of developing behavioural side effects due to corticosteroid treatments. It is reasonable to consider that the same may happen in dogs with pre-existing behavioural problems. In this paper, the possible behavioural side effects of exogenous corticosteroids are summarised to help inform and support veterinarians prescribing these drugs.

The Recurrence of Motor Tics Mediated by Oral Prednisolone Use in Autistic Children: A Case Report

OBJECTIVES

This study aimed to report motor tics worsening by prednisolone acute treatment, despite the use of aripiprazole and clonidine. It was also aimed to discuss the mechanisms involved in neuropsychiatric adverse effects with the use of corticosteroids.

METHODS

It was reported a 7-year-old boy patient with a history of autism spectrum disorder and motor tics. He has remitted motor tics with an association between aripiprazole and clonidine. However, was registered motor tics' recurrence with acute use of prednisolone.

CONCLUSIONS

The neuropsychiatric adverse effects mediated by corticosteroid use are low explored, mainly in pediatric clinical practice. The prednisolone prescription is widespread in childhood and, considering some vulnerable conditions to this type of adverse effects, is imperative.

Differences in Adverse Effect Profiles of Corticosteroids in Palliative Care Patients

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.

Steroid-induced mental disorders in cancer patients: a systematic review

Corticosteroids are a central part of many cancer treatment regimens. Neuropsychiatric toxicity has complicated their use, including an association with a spectrum of symptoms, from insomnia, cognitive impairment and mood symptoms, to severe mental disorders, including mania, psychosis and severe depression. Although steroid-induced mental disorders were first reported in medicine more than 60 years ago, there is a dearth of evidence available to date on optimal treatment and prevention to guide cancer clinicians. We completed a systematic review of the current evidence for therapeutic and prophylactic interventions of steroid-induced mental disorders in cancer. We searched Medline, Embase and PsycINFO and selected studies related to steroid-induced mental disorder. The studies found were limited to case series and case reports only.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

[Pain therapy in patients with schizoaffective disorder and cancer]

We report on two patients with schizoaffective psychosis, cancer, and pain. However, it is not possible to make somatic or psychic disturbances alone responsible for the pain. In patients with current schizoaffective disorders, only administration of a combination of psychopharmaceutical and opioid agents is successful.

Corticosteroid prescribing in palliative care settings: a retrospective analysis in New Zealand

BACKGROUND

Corticosteroids are a potent group of medicines, with many adverse effects, that are widely prescribed in palliative care for both specific and non-specific indications. The aim of this study was to document current patterns of corticosteroid prescribing in New Zealand palliative care settings and to reflect on whether they were in line with international experience.

METHODS

A retrospective review of inpatient use of corticosteroids was undertaken in a sample of six New Zealand hospices. Data were collected on numbers of patients prescribed corticosteroids, indications for use, choice of agent, doses and dosage changes, duration of course, incidence of adverse effects, method of stopping, use of guidelines, and processes for monitoring and review.

RESULTS

The case notes of 1179 inpatients were reviewed and 768 patients (65.1%) had received at least one course of corticosteroids. There was a marked consistency in the proportion of patients prescribed corticosteroids among the sample hospices (61-69%). Detailed information was recorded for a sample of 260 patients. Corticosteroids were prescribed most commonly for non-specific reasons (40.4% of prescribing events), followed by neurological (25.3%) and soft tissue infiltration symptoms (14.4%). The agent of choice was dexamethasone with a dose range of 1 mg to 40 mg and a median dose of 8 mg. The median course duration for all corticosteroid prescribing events was 29 days. Abrupt stopping occurred in 72 (23.2%) cases, of these 35 (49%) had been on a course of corticosteroids for more than three weeks. Guidelines were only available in one hospice. Monitoring and review was documented in 135 (52%) of cases, and adverse effects were recorded in 82 (32%); these are likely to be underestimates due to a high level of non-recording.

CONCLUSIONS

This New Zealand study showed that corticosteroids are widely prescribed in palliative care, most commonly for non-specific indications. These findings are consistent with the international literature in this area and this large, multi-site study adds weight to the findings and the need for ongoing discussion about the place of these drugs in palliative care.

Psychiatric complications of treatment with corticosteroids: review with case report

Corticosteroids are widely used in modern medicine but can result in troubling psychiatric side-effects. Physicians and other medical professionals should be aware of the potential for these side-effects, possible means of prevention, and efficacious treatments. Herein, we review adult case report data published during the past quarter-century on adverse corticosteroid-induced psychiatric effects, and present a case of corticosteroid-induced psychotic depression. PubMed and PsychLit databases were searched using the terms 'corticosteroids', 'steroids', and the generic names of corticosteroid medications with terms for psychiatric symptoms or syndromes, including psychosis, mania, hypomania, depression, apathy, anxiety, panic, depersonalization, delirium, confusion, hallucinations, delusions, paranoia, cognitive impairment and dementia. Fifty-five cases and a number of clinical trials investigating the incidence and treatment of these psychiatric symptoms and syndromes were identified. Data on incidence, drug dose, risk factors, course of illness and treatment (when present) were tabulated. We conclude that the cumulative data indicate that psychiatric complications of corticosteroid treatment are not rare and range from clinically significant anxiety and insomnia, to severe mood and psychotic disorders, delirium and dementia. While tapering or discontinuation of the corticosteroid treatment may remedy these adverse side-effects, psychotropic medications are often required because of the medical necessity of the corticosteroid or the severity of the psychiatric symptom. Further studies are needed to better understand the deleterious psychiatric effects associated with corticosteroids.