Management of intracranial tumours in the acute setting

Acute Oncology Guidelines
NHS Lothian

Guidelines for use of steroids for primary & metastatic intra-cranial lesions (GG/4)

The flow chart in the section below shows the acute medical guidelines for initial management of newly diagnosed brain lesion. 

Patients with known cancer and brain metastases should be discussed with a site specialist oncologist (if not urgent contact their oncology consultant or if urgent via on call oncology STR).  

Referral to neuro-surgery or ECNO MDM only indicated when surgery or radiosurgery (SRS) are being considered (see OOQS for referral guidance) - only available on NHS Lothian intranet. 

Edinburgh Centre for Neuro-oncology guidance for the management of intracranial tumours in the acute setting

Edinburgh Centre for Neuro-oncology guidance for the management of intracranial tumours in the acute setting

This algorithm aids clinical decision making for patients presenting to the Emergency Department / Acute Receiving Unit with an intracranial lesion felt to most likely represent a primary brain tumour or metastatic deposit. Many of the frequently asked questions are answered in the further information sections of the algorithm but specialist help should be sought for any additional queries not answered within this guidance. 

Please direct any comments, questions or feedback to Dr S Erridge, Consultant Neuro-oncologist.

Good prescribing practice for corticosteroids

Table 1: Good prescribing practice for corticosteroids
1 Document indication for the corticosteroid on the patient's kardex and in notes.
2 Steroids have long half-life so can be prescribed once a day after breakfast. If the patient prefers to have the dose split, then do not give after 14.00. Dexamethasone comes in 4mg, 2mg and 0.5mg (500 microgram) tablets.
3

Start gastric protection with a PPI (e.g. omeprazole 20mg od)

Note PPI increase risk of C Difficile and can cause hyponatraemia (change to ranitidine)and stomatitis, so should be stopped 7 days after steroids (if no ongoing GI symptoms)
4 Ensure appropriate patient information regarding corticosteroids (importance of not stopping suddenly, dietary advice) and dose reduction regimen on discharge. Counsel if necessary.
5

Monitor all patients on high dose steroids for:
  • The steroid dose should be reviewed regularly, and if possible, reduced.  
  • The speed of reduction will depend on interventions used (e.g. discontinuing after complete resection, or radiotherapy for radiosensitive tumour) 
  • In general, they should be reduced by around 25% every one to two weeks to the lowest level at which the patient remains well 
  • It takes at least three days for the impact of reduced steroids to have an impact so symptoms within this period may not be related to steroid reduction. 
  • If the tumour (metastases) progress the dose may need to be increased. 

Table 2: Examples of reducing course - speed depends on individual's symptoms and raised pressure on MRI.

Week 1 16mg
Week 2 12mg
Week 3 8mg
Week 4 6mg
Week 5 4mg
Week 6 3mg
Week 7 2mg
Week 8 1.5mg
Week 9 1.0mg
Week 10 0.5mg
Week 11 stop

 

Week 1 8mg
Week 3 6mg
Week 5 4mg
Week 7 3mg
Week 8 2mg
Week 8+ Decision made after clinical and imaging review to keep at 2mg.

If patient struggles to come off steroids due to withdrawal symptoms (fatigue, aches and pains) options include: 

  • Alternate day dexamethasone 0.5mg alt day for two weeks.
  • Conversion to prednisolone (1mg dexamethasone = 7mg prednisolone) 
  • Synacthen test – liaise with endocrinology.

Editorial Information

Last reviewed: 05/01/2024

Next review date: 05/01/2027

Author(s): Edinburgh Cancer Centre, Western General Hospital, El-Shakankery K, Hopkins S, Erridge S.

Version: 1.0

Author email(s): karim.el-shakankery2@nhs.scot, samantha.hopkins@nhslothian.scot.nhs.uk.

Approved By: CTAC. Refer to Q-Pulse for approval details.

Reviewer name(s): Stewart J.