Managing Steroid Psychosis When Steroid Is Essential — SCE Palliative Medicine MCQ

Correct answer: A — Reduce dexamethasone to the minimum effective dose and add low‑dose haloperidol 0.5–1 mg for acute symptom control; complete cessation may not be possible if dexamethasone remains essential for cerebral oedema

Explanation lettering: B = shown as A · E = shown as B · A = shown as E

Steroid‑induced neuropsychiatric complications are common with high‑dose dexamethasone and most improve with dose reduction; specific symptom control may require antipsychotics such as haloperidol at low doses. NICE recommends early steroid dose reduction in brain metastases, and MHRA and the dexamethasone SmPC advise that psychiatric reactions often resolve with dose reduction, though treatment may be necessary. Haloperidol is endorsed by NICE for short‑term management of delirium when symptoms are distressing. Option B correctly combines dose optimisation and acute symptom control. Transferring to psychiatry delays necessary steroid management (A). Abrupt cessation risks cerebral oedema (C); increasing the dose worsens psychiatric toxicity (D); quetiapine at high dose without steroid reduction fails to address both causes and risks oversedation (E).

Reference: NICE NG99 Recommendations on steroid use in brain metastases (2021); GOV.UK MHRA Drug Safety Update on corticosteroid psychiatric side‑effects (2014); NICE CG103 Delirium guidance (2010), https://www.gov.uk/drug-safety-update/corticosteroids-early-psychiatric-side-effects