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Sudden withdrawal of corticosteroids: A commentary

Robert was a 75-year-old homebound male with widely metastatic colon cancer to the liver and lung. He had undergone colonic resection and placement of a colostomy and had deep venous thrombosis requiring warfarin therapy. Although he did well postoperatively, Robert eventually developed significant generalized pain, anorexia, cachexia, and peripheral edema. Hydromorphone was prescribed for the pain and titrated to an oral dose of 16 mg four times daily, which reduced his discomfort considerably. However, he repeatedly complained of right upper-quadrant pain, loss of appetite, weight loss, and “swelling” of his lower extremities. Dexamethasone was added to his medication regimen at an oral dose of 8 mg daily to reduce presumed hepatic capsular distension, increase his appetite, and reduce peripheral edema through peritumor reduction. For a few weeks, the dexamethasone seemed to lessen Robert’s symptoms. However, his disease process worsened, and the hydromorphone was increased to 24 mg four times daily while the dexamethasone was increased to 8 mg twice daily. In spite of the increased doses, Robert continued to decline. At one point, Robert suddenly became lethargic and was unable to swallow oral medications. A subcutaneous infusion of hydromorphone was initiated; however, the dexamethasone was abruptly discontinued. Robert become comatose and died five days later with his family at his bedside. Upon review of Robert’s case, concern arose as to whether sudden withdrawal of the dexamethasone contributed to his death by causing cardiovascular shock secondary to adrenal crisis.