Steroids in anti-inflammatory

Complication

Prevention (key points)

Treatment (key points)

Hyperglycemia

Counsel patients on diet and exercise.

Patients with type 1 diabetes (or with type 2 diabetes on insulin) who are receiving glucocorticoid therapy and whose fasting plasma glucose is below 13 mmol/L can be followed in the oncology clinic together with their primary care physician. If their fasting plasma glucose is greater than 13 mmol/L, they should be referred to an endocrinologist or diabetologist.

Myopathy

Use lowest effective dexamethasone dose; encourage fitness, aerobic exercise, and weight training; avoid skin breakdown by minimizing repetitive shear forces on patient’s skin during all types of exercise.

Lower dose or switch medication might reduce extent of myopathy; consider switching from fluorinated to non‑fluorinated corticosteroid to reduce myopathy.

Osteoporosis, avascular necrosis

Encourage bone health: weight‑bearing exercise, calcium (diet + supplements) 1200 mg/day, vitamin D 800–2000 IU/day, fall‑prevention; for life expectancy >6 months, consider bisphosphonate at the outset for duration of glucocorticoid therapy in adults >50 years or on long‑term glucocorticoid therapy (>3 months).

Refer patients with complications to endocrinologist or rheumatologist; refer to orthopaedic surgeon for compression fractures.

Peptic ulceration, bowel perforation

Use prophylactic proton‑pump inhibitors in patients with ulcer/gastrointestinal bleeding history or on NSAIDs, aspirin, or anticoagulants; consider H₂ blockers or PPIs as appropriate; use laxatives (PEG or lactulose) to prevent constipation and bowel perforation.

PPIs are drugs of choice for peptic ulcers including NSAID‑induced ulcers; lansoprazole, omeprazole, pantoprazole have similar efficacy at standard doses.

Anxiety, irritability, insomnia, mania, psychosis, depression, seizures

For insomnia: lowest effective corticosteroid dose, avoid long daytime naps, regular sleep/rest schedule, avoid smoking/alcohol/caffeine before sleep, avoid vigorous exercise before bed, use relaxation strategies (meditation, warm baths and music).

Sedatives for insomnia such as zopiclone or temazepam; refer to mental health professionals, social worker or spiritual counsellor for moderate–severe distress; psychotherapy plus antidepressant ± anxiolytic for anxiety/mood disorder; for psychosis, an effort should be made to stop dexamethasone or to gradually reduce the dose. Neuroleptics and lithium might be considered in consultation with psychiatrist.

Pneumocystis jirovecii pneumonia (PJP), candidiasis

Consider prophylactic therapy with trimethoprim–sulfamethoxazole against PJP in brain‑cancer patients on prolonged corticosteroids.

Treat PJP infection with trimethoprim–sulfamethoxazole, trimethoprim plus dapsone, atovaquone suspension, clindamycin plus primaquine, or pentamidine. Oropharyngeal candidiasis should be treated with nystatin, fluconazole, or itraconazole.

Venous thromboembolism (VTE)

Routine antithrombotic prophylaxis not recommended; prophylaxis with low‑molecular‑weight heparin (such as dalteparin, enoxaparin, or tinzaparin), fondaparinux, unfractionated heparin, or warfarin may be appropriate for people who are judged to be at risk of venous thromboembolism after assessing their risk factors.

Low‑molecular‑weight heparin preferred for cancer patients with established VTE and for long‑term anticoagulation.

Hypertension, increased cardiovascular risk

No clear evidence for routine prevention and treatment of corticosteroid‑induced hypertension; monitor blood pressure, especially in first months of therapy; consider measures in patients with corticosteroid‑induced lipodystrophy.

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