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The role of steroids in the management of brain metastases: a systematic review and evidence-based clinical practice guideline |
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| Authors: | Timothy C. Ryken Michael McDermott Paula D. Robinson Mario Ammirati David W. Andrews Anthony L. Asher Stuart H. Burri Charles S. Cobbs Laurie E. Gaspar Douglas Kondziolka Mark E. Linskey Jay S. Loeffler Minesh P. Mehta Tom Mikkelsen Jeffrey J. Olson Nina A. Paleologos Roy A. Patchell Steven N. Kalkanis |
| Affiliation: | 1. Department of Neurosurgery, Iowa Spine and Brain Institute, Iowa City, IA, USA 2. Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA 3. McMaster University Evidence-Based Practice Centre, Hamilton, ON, Canada 4. Department of Neurosurgery, Ohio State University Medical Center, Columbus, OH, USA 5. Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA 6. Department of Neurosurgery, Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA 7. Department of Radiation Oncology, Carolinas Medical Center, Charlotte, NC, USA 8. Department of Neurosciences, California Pacific Medical Center, San Francisco, CA, USA 9. Department of Radiation Oncology, University of Colorado-Denver, Denver, CO, USA 10. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA 11. Department of Neurosurgery, University of California-Irvine Medical Center, Orange, CA, USA 12. Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA 13. Department of Human Oncology, University of Wisconsin School of Public Health and Medicine, Madison, WI, USA 14. Department of Neurology, Henry Ford Health System, Detroit, MI, USA 15. Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA 16. Department of Neurology, Northshore University Health System, Evanston, IL, USA 17. Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA 18. Department of Neurosurgery, Hermelin Brain Tumor Center, Henry Ford Health System, 2799 West Grand Blvd, K-11, Detroit, MI, 48202, USA |
| Abstract: | QuestionDo steroids improve neurologic symptoms in patients with metastatic brain tumors compared to no treatment? If steroids are given, what dose should be used? Comparisons include: (1) steroid therapy versus none. (2) comparison of different doses of steroid therapy. Target population These recommendations apply to adults diagnosed with brain metastases. Recommendations Steroid therapy versus no steroid therapy Asymptomatic brain metastases patients without mass effect Insufficient evidence exists to make a treatment recommendation for this clinical scenario. Brain metastases patients with mild symptoms related to mass effect Level 3 Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. It is recommended for patients who are symptomatic from metastatic disease to the brain that a starting dose of 4–8 mg/day of dexamethasone be considered. Brain metastases patients with moderate to severe symptoms related to mass effect Level 3 Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. If patients exhibit severe symptoms consistent with increased intracranial pressure, it is recommended that higher doses such as 16 mg/day or more be considered. Choice of Steroid Level 3 If corticosteroids are given, dexamethasone is the best drug choice given the available evidence. Duration of Corticosteroid Administration Level 3 Corticosteroids, if given, should be tapered slowly over a 2 week time period, or longer in symptomatic patients, based upon an individualized treatment regimen and a full understanding of the long-term sequelae of corticosteroid therapy. Given the very limited number of studies (two) which met the eligibility criteria for the systematic review, these are the only recommendations that can be offered based on this methodology. Please see “Discussion” and “Summary” section for additional details. |
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