They are used for a variety of malignant conditions, particularly acute lymphoblastic leukaemia (ALL), lymphoma and Hodgkin’s disease in which steroids play an important role in treatment. Children and adolescents with a brain tumour often receive steroids as part of initial treatment.
The role of steroids in supportive care includes symptom management in paediatric palliative care, where steroids are most commonly used in high doses for a few days. They also have a role in prevention of nausea and vomiting in certain chemotherapy regimens.
What are steroids?
“Steroids are hormonal substances, naturally produced in the body by the adrenal glands and the reproductive organs.”[1].They work by interfering with protein synthesis and cellular metabolism by binding with intracellular glucocorticoid receptors [2]. Saturation of these receptors induces apoptosis (cell death).
Steroids commonly used in childhood and adolescent cancers
Dexamethasone is a fluorinated glucosteroid while prednisolone is non fluorinated. Both have an essential role to play in treatment of childhood and adolescent cancer.
It is widely accepted that dexamethasone is the steroid of choice in the treatment of acute lymphoblastic leukaemia (ALL) due to its ability to kill leukaemia cells. It is the basis for the current UKALL 2011 trial [3]. Doses must be discussed with the Principal Treatment Centre and follow the treatment protocol
Dexamethasone is an effective drug in reducing swelling of the brain in children and young people with a brain tumour.
Dexamethasone can also be prescribed as an antiemetic in patients with severe vomiting secondary to chemotherapy treatment for sarcomas, neuroblastoma, and higher-risk Wilms' tumour. There are limitations to its use as an antiemetic including maximum of five days of prescription and never in leukaemias or lymphomas.
Prednisolone is often used in the treatment of hemophagocytic lymphohistiocytosis (HLH), Langerhans cell histiocytosis (LCH), Hodgkin’s and non-Hodgkin’s lymphomas. Dosing varies depending on the protocol (please check with the Principal Treatment Centre for doses) usuallly for 7- 15 days or in the case of HLH and LCH may be prolonged over a number of weeks and gradually weaned. [4].
GP note
Steroids are very effective in the treatment of lymphoid malignancies such as acute lymphoblastic leukaemia (ALL) and non-Hodgkin’s lymphoma. If either of these diagnoses is a consideration, corticosteroids must not be given before referral as they may partially treat the patient making confirmation of the diagnosis difficult and risking tumour lysis syndrome. Prior treatment with corticosteroids may also make the patient ineligible for the current UKALL trial for ALL and may have an adverse impact on prognosis.
Side effects
Unfortunately there are many common side-effects of corticosteroids,
- Avascular necrosis (link)
- Myopathy (link)
- Challenging behaviour (link)
- Obesity / cushingoid features / stretch marks (link).
- Stomach upset / GI bleeds (Omeprazole is used prophylactically) Gastrointestinal (GI) adverse effects range from indigestion to ulceration and most patients having steroids are placed on GI protection such as ranitidine or omeprazole
- Hearing loss
- Immunosupression (Link Febrile Neutropenia)
- Hypertension
- Hyperglycaemia
- Acne
- Pituitary-adrenal axis suppression.
- Altered sleep patterns and fatigue (Links)
Less common effects include psychiatric disorders, increased intraocular pressure, osteoporosis and osteopenia (Link to AVN). The multi-disciplinary team (MDT) treating children and young people with cancer will face a challenge in reaching a balance between maximising the anti-cancer effect of steroids whilst minimising the short and longer term side-effects of the drug. Having an understanding of the side-effects of steroids and how these may present in a clinical setting, will help the MDT in providing the best care for child or young person with cancer.
Further reading
CCLG produces a factsheet on dexamethasone, including information to help manage the behaviour of children taking steroids.
CCLG dexamethasone drug factsheet
References
[1] MacMillan (2013) Steroids http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/Treatmenttypes/Supportivetherapies/Steroids.aspx
[2] Chordas C & Graham K (2010) in Tomlinson D and Kline N (2010) Pediatric Oncology nursing: Advanced clinical Handbook chpt 9 Springer
[3] [University of Birmingham] Children’s Cancer Trial Team (2011) Cancer Research Clinical Trials Unit