Background     Corticosteroids are recommended as an adjuvant analgesic for cancer-related bone pain.  The mechanism of action is likely related to decreasing tumor-related edema or inhibition of prostaglandin and leukotriene synthesis.  This Fast Fact discusses the use of corticosteroids for painful bone metastases and prevention of pain flares associated with radiation of bone metastases. See Fast Fact #395 for a discussion about corticosteroids for other malignancy-related symptoms.  

Corticosteroid selection and dosing     The ideal corticosteroid and dose for cancer-related bone pain is unknown. Current practice is derived from expert opinion, case series, and a limited number of clinical trials. Starting doses reported in the literature are wide-ranging; however, there are some areas of consensus worth noting. 

• Agent: dexamethasone is likely the most prescribed corticosteroid for cancer-related bone pain due to its lower mineralocorticoid effect and long half-life, which allows once-daily dosing.  
• Dose for cancer-related bone pain: most studies support total daily doses of 2 to 8 mg of oral dexamethasone either given once in the AM or divided over BID dosing. 
• Dose for an acute pain crisis from bone pain: in the event of an acute pain crisis unresponsive to parenteral opioids, some experts suggest a loading dose of 8-10 mg x1 followed by 4 to 8 mg BID, with the goal of tapering to the lowest dose that continues to provide adequate analgesia. 
• Dose for prevention of pain from radiation therapy of bone metastases: a systematic review of several randomized controlled trials found that corticosteroids led to a significant relative risk reduction of 43% in the incidence of pain flares from radiation therapy to bone metastases. Dexamethasone 8 mg oral daily for 5 days is a commonly described dose regimen for this indication. 
• Dose for other types of pain: Dexamethasone daily dose of 8 mg has been described to help with neuropathic pain and liver capsular pain from cancer. 

Duration of therapy     While the optimal duration is unknown, a corticosteroid taper is usually not necessary if taking 4 mg or less of dexamethasone for less for 3 weeks or less.   Therefore, if no benefit is seen within 5-7 days, the corticosteroid likely can be discontinued.  If beneficial, the drug should be tapered to the lowest effective dose or, if possible, discontinued to avoid long-term adverse effects.  

Side effects account for discontinuation of steroids in 5% of patients. The risk of side effects correlates with dose and duration of treatment.  

• Early side effects (days): thrush (~30%), edema (20%), dyspepsia, peptic ulcer diseases, symptoms (insomnia, delirium, and anxiety) (see Fast Fact #323), glucose intolerance.   
• Delayed side effects (weeks to months): adrenal suppression, myopathy leading to proximal muscle weakness in limbs, moon facies/fat redistribution, susceptibility to infection, osteoporosis, skin fragility, impaired wound healing.   
  • A prospective review of inpatients with advanced cancer demonstrated that dexamethasone and prednisone have a similar side effect profile, although at equipotent doses dexamethasone causes slightly more thrush and psychiatric symptoms but less edema and dyspepsia.   
  • The relationship between peptic ulcer disease and steroids is controversial; in one nested case-control study it appeared correlated with concurrent NSAID use and a cumulative dose greater than 1000 mg of prednisolone or 140 mg of dexamethasone.   
  • Case reports and prospective series suggest that psychiatric symptoms are observed most in middle-aged women, are directly related to dosage, and usually resolve with dose reduction.  

Summary     Steroids are recommended for use in cancer-related bone pain, but the choice of dose, duration and specific drug is largely empiric.  Steroid toxicities are a concern; the duration of treatment should be minimized to reduce the risk of adverse events. 

Resources 

1. Berger AM, Koprowski C. Bone pain: assessment and management. In: Berger AM, Portenoy RK, Weissman DE, eds. Principles and Practice of Palliative Care and Supportive Oncology. 2nd edition. Philadelphia, PA: Lippincott, Williams and Wilkins; 2002.  
2. Pereira J. Management of bone pain. In: Portenoy RK, Bruera E, eds. Topics in Palliative Care Volume 3. New York, NY: Oxford University Press; 1998.  
3. Bruera E, Roca E, Cedaro L, et al. Action of oral methyl-prednisolone in terminal cancer patients: a prospective randomized double-blind study. Cancer Treat Rev. 1985; 69:751-754.  
4. Twycoss R. The risks and benefits of corticosteroids in advanced cancer. Drug Safety. 1994; 11(3):163-178.  
5. Hanks GW, Trueman T, Twycoss RG. Corticosteroids in terminal cancer-a prospective analysis of current practice. Postgraduate Med J. 1983; 59(697):702-706.  
6. Klein JF. Adverse psychiatric effects of systemic glucocorticoid therapy. Am Fam Phys. 1992; 46(5):1469-1474.  
7. Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. Annals Intern Med. 1991; 114:735-740.  
8. Yousef AA, El-Mashad NM. Pre-emptive value of methylprednisolone intravenous infusion in patients with vertebral metastases. A double-blond randomized study. J Pain Symptom Manage. 2014; 48(5):762-769.  
9. Leppert W, Buss T. The role of corticosteroids in the treatment of pain in cancer patients. Curr Pain Headache Reo. 2012; 16:307-313.  
10. Fabregat C, Almendros S, Navarro-Martin A, Gonzalez J. Pain Flare-Effect Prophylaxis with Corticosteroids on Bone Radiotherapy Treatment: A Systematic Review. Pain Pract. 2020 Jan;20(1):101-109. 
11. Barghi K, Edmonds KP, Ajayi TA, Atayee RS. Prescribing Trends of Palliative Care Team’s Use of Dexamethasone for Cancer-Related Pain. Journal of Pain & Palliative Care Pharmacotherapy. 2018;32(1):37-43. 

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in January 2005. 2nd Edition published in April 2009; 3rd Edition in October 2015 by Mary Rhodes MD; 4th Edition in January 2024 by Sarah Cagle MD.