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Corticosteroid Tapering Protocol — SCE Palliative Medicine MCQ

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ModeratePain ManagementCorticosteroid Tapering ProtocolSCE Palliative Medicine

A 72‑year‑old woman with advanced breast cancer has been on long‑term dexamethasone 4 mg daily for liver‑capsule pain from hepatomegaly. She now has bilateral proximal weakness, moon face and buffalo hump consistent with iatrogenic Cushing syndrome. She asks whether the steroid can be stopped. What is the most appropriate approach?

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Correct answer: B — Taper dexamethasone to the lowest effective dose

Explanation lettering: C = shown as A · E = shown as C · A = shown as D · D = shown as E

Option B is correct. In UK palliative care, long‑term dexamethasone (greater than about 3 weeks and doses above physiological equivalent) requires gradual tapering to avoid adrenal insufficiency and allow HPA axis recovery, while balancing symptom control. Guidelines (NHS Palliative Care Pain & Symptom Control) recommend halving the dose to ~2 mg then reducing by 0.5–1 mg weekly with monitoring of recurrence of liver capsule pain as the guiding indicator of maintenance dose; if the patient remains pain‑free at cessation, steroid may be stopped. NICE NG243 similarly advises tapering through physiological replacement and stepwise staggering. Options A, C, D, and E are unsafe or ethically unsound: testosterone is irrelevant; increasing steroid worsens Cushing; abrupt cessation risks adrenal crisis; indefinite continuation ignores serious iatrogenic harms.

Reference: Palliative Care Pain & Symptom Control Guidelines (NHS, 2020); NICE NG243 managing glucocorticoid withdrawal (2024): https://bnf.nice.org.uk/