Maeda, T., & Hayakawa, T. (2016). Combined effect of opioids and corticosteroids for alleviating dyspnea in terminal cancer patients: A retrospective review. Journal of Pain and Palliative Care Pharmacotherapy, 30, 106–110.

To evaluate the differences in the effects of various opioids administered concurrently with corticosteroids on severity of dyspnea in patients with terminal-stage cancer.

This study retrospectively investigated the EHRs of patients with terminal cancer who were hospitalized, received oral or IV corticosteroid treatment with an opiate medication for dyspnea, and died while hospitalized. Patients were excluded if they received invasive interventions, received oral corticosteroids prior to admission, or did not receive both medications concomitantly. The effectiveness of combined opioids and corticosteroids treatment for dyspnea was assessed from the first to last administration using the STAS-J. The effectiveness of combined opioids and corticosteroid treatment for dyspnea was compared with time of corticosteroid initiation and maximum effect against dyspnea, as determined by changes in the evaluation score. Data was recorded daily from initiation to death. Opioid doses were recorded to the point at which max efficacy could be confirmed (responders) and at the time at which the assessment began (nonresponders) and compared between groups.

• N = 20 patients; 49 were screened and 29 did not meet full inclusion criteria  
• AGE: Mean age = 71 years (range = 49-94)
• MALES: 65%  
• FEMALES: 35%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Terminal cancer; primary lesions mainly colon cancer, stomach cancer, or lung cancer. 70% of patients presented with pleural effusions, 25% had lung area metastatic spread, and 15% had lymphangitis carcinomatosis.  
• OTHER KEY SAMPLE CHARACTERISTICS: Median opioid dose 30 mg

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Kasugai Municipal Hospital, Japan

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Retrospective review

Wilcoxon signed-rank test was used to test the effectiveness of opioids in the terms of changes in the STAS-J score. This tool contains many questions about symptoms. The authors stated they used “only questions concerning effectiveness of combined opioid and corticosteroid treatment and opioid doses. They reported score changes as their measurement of interest, but it is unclear if this was a total STAS-J score or a subscale score. It is uncertain if this tool has been validated using individual questions. Logistic regression analysis was used to compare the opioid doses and responders versus nonresponders. Responders were defined as a patient who the STAS-J score decreased by greater than or equal to 2 points. Nonresponders were defined as a patient whose STAS-J score did not decrease or only decreased by 1 point.

Significant difference in STAS-J score at initiation and lowest STAS-J score (p = 0.0034) for patients currently treated with morphine and corticosteroids. STAS-J scores increased by 2 or more points in 14 patients with concomitant opioid and corticosteroid use. The logistic regression analysis did not show a significant impact of the opioid dose on dyspnea alleviation.

Use of morphine and corticosteroids has the potential to alleviate dyspnea in patients with terminal cancer. More research is needed to determine the efficacy of opioids and corticosteroids in reducing dyspnea.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Measurement/methods not well described
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: The scale used for measurement of dyspnea is a multi-item scale but the authors used only selected questions and did not validate the reliability of using select questions. It is unclear how selecting questions influenced the total score that is reported.

Nurses may consider combining corticosteroids and opiates for management of dyspnea in terminally ill patients. Nurses need to be aware of the potential adverse reactions associated with both opioids and corticosteroids and educate patients on such. Nursing needs to be aware of the various routes of administration for corticosteroids and opioids.