Glucocorticoids are one of the most commonly used treatments and adjuvant drugs in oncology, especially dexamethasone is used in a very wide range, and the therapeutic dose, course of treatment and timing of administration of different treatment destinations of Saimethasone are often different, which makes it easy for us to remember and confuse.
Today we review the need to use glucocorticoids in cancer patients, as this article does not contain glucocorticoid use in hematological tumors due to space limitations.
Pretreatment of the drug
The drugs that require glucocorticoid pretreatment are: docetaxel injection, paclitaxel/paclitaxel liposome injection, pemetrexed injection, cetuximab, and rituximab.
Although the instructions for cetuximab and rituximab clearly state that glucocorticoid pretreatment is required, glucocorticoid drugs are not recommended. We use monoclonal antibody-based antineoplastic drugs other than immune checkpoint inhibitors in people with allergies, and we can use glucocorticoids as appropriate.
Recommended dosage courses for dexamethasone use in pretreatment:
Note: d0 is 1 day before chemotherapy, d1 is the day of chemotherapy, and d2 is on day 2 of chemotherapy.
Paclitaxel Injection Pretreatment Dexamethasone Reduction or Discontinuation Pretreatment Regimen: Allergic reactions to taxa drugs occur in most patients with the first or second dose, so standard precautions must be taken with the first two uses.
Considering the hormone-related adverse reactions that may occur with a large number of glucocorticoids, a simplified pretreatment regimen of glucocorticoids may be selected, including a dexamethasone reduction pretreatment regimen and a dexamethasone discontinuation pretreatment regimen, which is more suitable for patients with contraindications to hormonal medication or the use of hormones that are likely to cause serious adverse reactions.
Dexamethasone drug discontinuation pretreatment protocol lacks domestic large-scale clinical trial data, which still needs to be verified by large samples and prospective clinical studies, and the clinical reduction and discontinuation pretreatment protocols are recommended to be carried out on the basis of patient informed consent.
Central nervous system metastases (cerebral edema)
Glucocorticoids have been used as early as 1960 to treat patients with central nervous system metastases. Glucocorticoids can treat both neurological deficits and elevated intracranial pressure.
The mechanism by which glucocorticoids reduce pertumoral edema may be:
1. Inhibits the inflammatory response, mainly by inhibiting phospholipase A2 of the arachidonic acid pathway;
2. Stabilize the lysosomal membrane;
3. Rebuild the blood-brain barrier and reduce the leakage of the blood-brain barrier;
4. Reduce capillary leakage from tumor tissue;
5. Reduce cerebrospinal fluid production, reduce vascular density, and combat tumor angiogenesis.
Studies have shown that glucocorticoids are rapid in reducing edema, and changes in capillary permeability can be observed after 1 hour of application. Methylprednisolone and dexamethasone have less hydrocorticoid-like effects such as hydrocarotic retention than other glucocorticoids, so they are more suitable as therapeutic agents.
Studies have shown that methylprednisolone and dexamethasone have no difference in efficiency compared to each other, methylprednisolone has a weak inhibitory effect on the hypothalamic-pituitary-adrenal cortex axis, and it is not easy to have withdrawal reactions, and methylprednisolone can be given priority when patients with severe cerebral edema require high-dose application of hormones to quickly reduce edema.
The recommended dosage of the drug is as follows:
Dexamethasone: the total intravenous dose is 15 mg/day given in 2 to 4 divided doses, and the dose can be increased to 25 mg/day up to 25 mg/day for a duration of 14 days.
Methylprednisolone: 80 mg/day initially, 48 hours do not relieve the increase to 160 mg/day (80 mg bid) intravenous infusion. If symptoms are severe and accompanied by extensive edema, intravenous infusions of 160 mg/day (80 mg bid) may be given directly. Generally no more than 160 mg/day, although up to 500 mg/day (impact dose) has been reported, but the duration of treatment should be as short as possible, generally no more than 3 days.
Improves appetite
Dexamethasone is recommended: empiric therapeutic doses of 4 mg orally in the morning after meals, other common methods are: 2-2.5 mg/time in the morning and once at noon, 0.75-1.5 mg/time, 4 times a day.
In order not to affect the patient's sleep, it is generally not taken at night, and the use of motidine 20 mg or ranitidine 0.15 g can be added before bedtime to reduce the occurrence of peptic ulcers.
Superior vena cava syndrome
If a patient receives emergency radiotherapy because of severe airway obstruction and is not suitable for stenting, a short course of high-dose corticosteroids (usually 3 to 5 days) may be given to minimize the risk of central airway obstruction caused by edema. The recommended dosages for related drugs are as follows:
Methylprednisolone: 80 mg/day initially, 48 hours do not relieve the increase to 160 mg/day (80 mg bid) intravenous infusion.
Dexamethasone: total intravenous infusion is given in 1 to 3 doses as appropriate, up to 25 mg/day.
Prevents vomiting caused by chemoradiation
For nausea and vomiting caused by chemotherapy drugs with a medium to high risk of vomiting and high doses of radiation therapy, we chose a regimen containing dexamethasone, and the recommended doses of dexamethasone are as follows:
About glucocorticoid reduction and discontinuation methods
In long-term glucocorticoid use, too rapid or abrupt withdrawal can produce hormone withdrawal syndrome, so we need to reduce the dose and gradually stop the drug.
The principles of hormone reduction and discontinuation are as follows: patients with short-term hormone (within 7 days) therapy and patients can be discontinued rapidly; patients with long-term hormone therapy should be gradually discontinued, usually reduced by 25% every 8 days, and maintained with long-term use of small doses of dexamethasone (1 to 2 mg/day).
bibliography:
1. Chinese Society of Clinical Oncology (CSCO) Guidelines for the Prevention and Treatment of Nausea and Vomiting Related to Antitumor Therapy 2019.V1.0 [M]. Beijing: People's Medical Publishing House
2. Yu Shiying,Du Guang,Huang Hongbing. Clinical Pharmacotherapeutics-Tumor[M]. Beijing: People's Medical Publishing House
3. Professional Committee of Multiple Primary and Unknown Primary Tumors of Chinese Anti-Cancer Association. Expert consensus on the clinical application of dose-intensive chemotherapy regimens for taxoids in China[J]. China Oncology,2019,29(11):910-920.
4. Health Office Medical Zhengfa [2011] No. 23. Guidelines for the Clinical Application of Glucocorticoid Drugs
The images in this article are provided by the author
Curator: GoEun, Mei Zhe
This article was first published on Lilac Garden's professional platform: Tumor Time