Monday, October 31, 2016

Cases: Use of Steroids as Adjuvants for Pain Management

by Emily Riegel

Clinical question:
Your patient* is a 60 y/o male with refractory AML, admitted with pneumonia. He is on broad spectrum anti-microbial therapy, including anti-fungal therapy, and has been stable since admission. Your team have been consulted to assist with pain management. His pain is pleuritic in nature, exacerbated by “twisting” or movements that involve change in position of his chest wall. It is not constant, and he has periods of time with no pain whatsoever, as long as he remains fairly still in his upper body. He has no other chronic or long-lasting pain issues. His primary team has written for him to have oxycodone immediate-release 10mg by mouth, which he is using 5-7 times a day, as well as hydromorphone 1 mg IV, which he is using 5-7 time daily in addition to the oxycodone.

Your plan:
You round on the patient over the weekend. As he does not have continuous or chronic pain, you decide not to add a long acting agent. You transition him to a single-opioid regimen of hydromorphone IV or PO as he felt the hydromorphone was more effective than the oxycodone. You also opt to add dexamethasone 4mg by mouth daily, starting on Saturday morning, as an adjuvant for pain control. The primary team agrees with your plan for a brief, 2 day course of dexamethasone. By Sunday afternoon, your patient reports he had little to no pain, was able to now walk 10 laps around the unit, and required only 2 doses of PO hydromorphone in the past 24 hours.

The dilemma:
In discussion with your colleagues at Monday morning handoff, one of your partners raises a concern about the use of a steroid in a patient with an active infection and an immune system already compromised by AML. Although you have frequently utilized steroids as an adjuvant for pain control as well as in the management of a multitude of other symptoms, and have done so with the blessing of the primary physicians, you find yourself now wondering if the concern over immunosuppression ought to be of greater concern to you.

To the literature we go!

Literature review:
Not surprisingly, upon research of this topic there is no literature that directly addresses this clinical question. Let’s look at what we can find, though. Use of glucocorticoids (we will henceforth simply use the term “steroids”) in the management of severe infections has been well documented in literature. It continues to be recommended for patients with severe septic shock, especially when hypotension is refractory to adequate fluid resuscitation and vasopressor treatment1.
There are also several studies, including multiple meta-analyses2 and a fairly recent randomized control trial that actually show an advantage in the concomitant use of steroids in managing community acquired pneumonia3.

In what may be the most similar scenario to your patient in terms of anticipated duration of steroid use, a literature review of use of single dose steroid to prevent post-op nausea and vomiting and risk of infection/delayed wound healing did not find increased occurrence of infection across multiple included studies4.

Conclusion:
Although there is no definitive, absolute proof that use of dexamethasone as an adjuvant agent for symptom management does not confer a potential increased risk of infection, we do have literature indicating that steroids are used to help manage and treat certain infections, and that there has not been evidence of increased new infections when used in a single dose post-operatively. The clinical take away here is that it okay to consider the use of a steroid, especially in a low dose for a short period of time, in managing pain of an inflammatory etiology (such as pleurisy), and when compared to the potential risks of other pain management strategies such as systemic opioids.

Emily Riegel, MD, is a Med/Peds Palliative Care Physician at the University of Kansas Health System.
References:
  1. Casserly B, Gerlach H, Phillips GS, et al. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Medicine. 2012;38(12):1946-1954. doi:10.1007/s00134-012-2720-z.
  2. Nie W, Zhang Y, Cheng J, Xiu Q. Corticosteroids in the Treatment of Community-Acquired Pneumonia in Adults: A Meta-Analysis. PLoS ONE. 2012;7(10). doi:10.1371/journal.pone.0047926.
  3. Torres A, Ferrer M. What’s new in severe community-acquired pneumonia? Corticosteroids as adjunctive treatment to antibiotics. Intensive Care Med Intensive Care Medicine. 2015;42(8):1276-1278. doi:10.1007/s00134-015-4042-4.
  4. Assante J, Collins S, Hewer I. Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. Accessed October 4, 2016. (Open Access PDF)

*Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. The case and discussion is published as a means to illustrate important teaching points in healthcare. Patient details may have been changed by Pallimed editors to ensnure anonymity. Links and minor edits are made for clarity and Pallimed editorial standards.

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