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Spinal Cord
Compression:
Pharmaceutical Issues
Rebecca Mills
Debra Howe Becs Walsh
Overview
Steroids
Why?
Adverse Effects
Gastro-protection
VTE Prophylaxis
Laxatives
Analgesia
Why use steroids?
Reduce inflammation around tumour
Reduce pain and improve neurological
function
Improve physical signs - reduced injury to
spinal cord
Choice and dose of steroid
Dexamethasone Available as injection, tablets or oral solution
High anti-inflammatory (glucocorticoid) effect, with minimal mineralocorticoid effects.
Long acting
16mg per day divided into 2 doses (8am & 2pm) N.B.= approx 100mg prednisolone
Trials compared 16mg per day with 96mg per day showed more side-effects with higher dose, but no greater effect
Gradual reduction Due to high dose (>40mg Pred)
Minimise risk of acute adrenal insufficiency
Every 3 days - See reducing regimen
Some patients will continue low dose (e.g. 2mg OD) steroids.
If symptoms worsen increase dose/reduce more slowly.
References NICE Guideline CG75
STH Cancer Nursing Care Guideline CN 301
WPH Reducing regimen
Day
Dexamethasone daily
dose Administration
1-3 16mg
16mg OM or 8mg
BD
(8am & 12noon)
4-6 8mg 8mg OM
7-9 4mg 4mg OM
10-12 2mg 2mg OM
13
Discontinue (unless on
maintenance dose)
Side-effects of Corticosteroids
Gastrointestinal irritation
Increased appetite, weight gain
Impaired glucose tolerance & diabetes Increase blood glucose monitoring
Refer to diabetic team
Psychiatric reactions – “steroid-induced psychosis” (mood changes)
Adrenal insufficiency Fatigue, Anorexia, nausea & vomiting
Check temp, Na, glucose, Hb
Long-term effects of steroid therapy
Immune suppression
Reduced healing/ability to fight infection
Caution chicken pox/ measles/influenza
contacts
Osteoporosis
Muscle weakness
Glaucoma
Cushing’s Syndrome
Cushing’s Syndrome
Gastro-protection
Be aware of high risk groups History of gastro-duodenal ulcer, gastrointestinal bleeding, or
gastro-duodenal perforation.
Older age.
Concomitant use of medications that are known to increase the risk of gastrointestinal bleeding.
Advanced cancer.
Prescribe lowest dose of steroid, for shortest time Review frequently.
Prescribe Proton Pump Inhibitor Lansoprazole 15mg OD (or continue existing dose/treatment)
Review when steroid stopped.
Points to remember Take with or after food to minimise gastric
effects
Use a PPI only whilst on steroid.
Try to avoid taking steroids after 4pm
Dexamethasone tablets dissolve or liquid is available (2mg in 5ml)
Check patient knows how/when to reduce their dose
Do not assume all patients stop steroids completely.
Avoid infectious contacts
Refer diabetic patients to diabetic nurses for additional monitoring.
Bowel Management
Constipation often associated with SCC
Can be one of the presenting symptoms
Maintaining regular bowel action is
important for patient comfort
Psychological issues also need to be
overcome e.g. patients embarrassment at
needing to be assisted with toileting
Review precipitation medications
Laxatives of choice
Docusate 100-200mg BD 1st line
Add Senna 2 ON PRN
Laxido/Movicol if impaction
Alternate Glyercin/Bisacodyl suppositories
if PR intervention needed.
Enemas may be required
Bulk-forming agents are less effective (e.g.
isphaghula/Fybogel)
VTE Prophylaxis
ALL inpatients – risk assessment (blue
form or in clerking)
SCC patients – high risk
Dalteparin
Anti-embolism stockings
Pain Control
Analgesia
Review current analgesia
Ensure adequate breakthrough
Titrate according to WHO ladder
See NICE - neuropathic pain
Any Questions?