Dexamethasone Therapy in Patients With Brain Tumors - A Focus on Tapering

Ann E. Nahaczewski; Susan B. Fowler; S. Hariharan

Disclosures

J Neurosci Nurs. 2004;36(6):340-343. 

In This Article

Adverse Effects

The myriad of adverse effects from corticosteroid therapy are well known to physicians, nurses, pharmacists, and patients. In general, adverse effects are dose- and time-dependent with 50% of patients experiencing at least one toxicity symptom. Commonly encountered adverse effects include hyperglycemia, gastritis, gastrointestinal bleeding, weight gain and moon faces, osteoporosis with chronic therapy, psychosis or euphoria, immunosuppression causing increased susceptibility to infection, and skin fragility and striae (DeAngelis, 1994; Vecht et al., 1994). In addition, steroid myopathy can occur, causing weakness primarily to proximal muscles of the upper and lower extremities and neck, which is frequently confused with progressive neurological disease.

Nurses may need to educate patients on management of blood sugar levels including possible use of insulin. To prevent gastrointestinal complications, encourage patients to take steroids with food and avoid aspirin and nonsteroidal anti-inflammatory drugs. Neuroscience nurses often confront body image disturbances of patients who experience weight gain and a "moon face" as a result of steroid use, requiring emotional support and counseling in dietary modifications such as low calorie snacks. Reassure patients that weight gain will not usually continue when dexamethasone is tapered off.

Musculoskeletal effects can be potentially disabling, so patients should be encouraged to exercise, if possible. Infection control measures include avoidance exposure to cold- and flu-like symptoms in others. Nurses will often need to assess patients' oral cavities for candida infection. If insomnia is a problem, sleep aids and avoidance of day time napping may help. Both patients and family members should be alerted to possible personality changes that may occur with dexamethasone use. Family members need to be included in education efforts, because they are often the individuals who note patient responses to treatment and changes in behavior.

Although most of these adverse effects occur with chronic corticosteroid therapy, patients often experience some of these with short-term therapy. The highest incidence of toxicity was evident in patients with serum albumin levels below 2.5mg/dl (Weissman, Dufer, Vogel, & Abeloff 1987). Because corticosteroids are highly bound to serum albumin, a decrease in the serum albumin level will result in a higher concentration of unbound corticosteroid in the circulation, thus increasing the potential for toxicity. Fortunately, serum albumin levels are usually not a problem in brain tumor patients.

Dose tapering can exacerbate pre-existing conditions such as pain, arthritis, asthma, dental conditions, and drug rash because of an antiepileptic drug. The treatment for an antiepileptic drug rash is to stop the drug; rarely are antihistamines or steroid creams ordered. The hepatic clearance of most antiepileptic medications is affected by steroids, necessitating careful monitoring of antiepileptic drug levels. Corticosteroids also decrease the effectiveness of oral contraceptives, therefore, dose adjustments and sexual counseling are needed in relevant patients. Thromboembolic risk may also increase in a patient population already at high risk for venous thrombosis.

Preventive measures can be initiated to avoid some of the more common adverse effects. Dietary counseling for optimizing nutritional status with a diet high in protein (to maintain an adequate serum albumin), vitamins, and micronutrients are recommended for the patient requiring chronic corticosteroid therapy. In addition, nutritional counseling can guide the patient in the selection of low-calorie and low-fat snacks for those who experience an increase in appetite and weight gain. Doses of corticosteroids may be taken with food. An antacid, or an H-2 antagonist or proton pump inhibitor may be added to the patient's medication regimen to reduce the incidence of gastritis and gastrointestinal bleeding.

Calcium and vitamin D supplementation can also be prescribed to reduce the loss of bone mass associated with long-term use of steroids. In addition, alendronate (Fosamax) and risedronate (Actonel) are prescribed to prevent steroid-induced osteoporosis and subsequent fractures. To date, risedronate is the only medication approved by the Food and Drug Administration for this use.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....