Steroids such as dexamethasone and prednisone are frequently used to treat myeloma patients. They reduce swelling and inflammation and have been shown to kill myeloma cells. However, steroids can also cause many serious side effects.

Both dexamethasone and prednisone can be prescribed alone or in combination with novel anti-myeloma drugs, which include thalidomide (Thalomid), Revlimid (lenalidomide), and Velcade (bortezomib). Prednisone is also used to enhance the response rate of melphalan therapy in myeloma patients.

Side effects caused by these steroids include, but are not limited to, sweating, insomnia, personality changes, infection, osteoporosis, cataracts, heartburn, high blood sugar, fluid retention, rash, and sexual dysfunction. The side effects observed are related to the dose and duration of use.

The National Cancer Institute (NCI) has created a scale for assessing side effects called the Common Terminology Criteria for Adverse Events (CTCAE). Side effects experienced by patients are assigned grades from one to five. Grade one side effects are mild, two are moderate, three are severe, four are life-threatening or disabling, and five refers to side effect-related deaths.

Communication between patients and doctors is vital for CTCAE to be useful in monitoring steroid therapies and moderating doses for patients. The CTCAE allows for comparison of the severity of side effects, which is extremely helpful when patients consult different specialists or when clinical treatments are compared.

Side effects can often be managed effectively with pharmacologic medications, non-pharmacologic remedies, or patient education as described in the following suggestions.

Steroid use can cause flushing and sweating, but these side effects may also be the result of thyroid dysfunction or perimenopause. If these other causes are ruled out, use of cold cloths or ice packs can help, along with drinking fluids to remain hydrated.

Water retention may be treated by lowering salt intake, elevating limbs, using elastic compression stockings, and doing physical activities. A common medicinal solution is diuretics.

Bone loss is a serious risk for myeloma patients. Patients with risk factors for osteoporosis such as older age, post-menopause, history of smoking, or presence of bone lesions should acquire a baseline bone density scan. Taking calcium while on a steroid therapy is not suggested, because it may interfere with drug absorption. Myeloma patients with bone lesions should consider bisphosphonate therapy to slow bone loss.

Patients suffering from personality changes should seek the help of support groups or psychological counseling. Dose reduction, discontinuation, modification of the treatment schedule, and psychoactive medications are possible pharmacological solutions.

Patients experiencing insomnia may take steroids early in the day so that they wear off by the evening. Alternatively, patients may take steroids right before bedtime, so the patient is asleep when the concentration of the drug is highest. Sedatives are a medicinal solution to insomnia.

White blood cell counts should be monitored for increases. If the white blood cell count rises above normal, it is necessary to watch for signs of infection. Prevention of infections is extremely important. However, if an infection occurs, treatment with antibacterial, antiviral, or antifungal medications will be needed.

Patients who discontinue high-dose steroid treatment often suffer from fatigue and muscle pain. To help lessen the severity of these side effects, a patient may take low-dose steroids for several days after the high-dose steroid regimen, and then reduce their dose over time. Reducing the dosage of steroid medication is extremely important. Sudden discontinuation should not be done, because this may cause severe side effects. Lowering steroid dosages should only be done under the supervision of the patient’s physician.

For more information, see the article "Steroid-Associated Side Effects In Patients With Myeloma" in the Fall 2008 issue of Myeloma Today (pdf).