Pain Flare-Effect Prophylaxis With Corticosteroids on Bone Radiotherapy Treatment: A Systematic Review

Background Radiotherapy for metastatic bone pain can induce a transitory increase in pain known as pain flare. Several studies have described the use of prophylactic corticosteroids to prevent pain flare. However, the role and efficacy of corticosteroids to prevent pain flare remain unclear. Purpose To summarize the available evidence with regard to the efficacy and toxicity of prophylactic corticosteroids for the prevention of pain flare. Methods This was a systematic review (PROSPERO protocol CRD42018090351) of peer-reviewed studies published in the Cochrane, Medline, and Scopus databases through September 2018. Studies carried out in adult patients treated with radiotherapy for bone metastases who received prophylactic corticosteroids to prevent pain flare were eligible for inclusion. The Cochrane Collaboration tool was used to assess risk of bias. The evidence grade was determined according to the GRADEpro tool. Results A total of 4,407 studies were identified. Of these, 4 clinical trials (CT) and 1 prospective cohort study met the inclusion criteria. The overall incidence of pain flare was 28%, and 21% vs. 37% in the prophylaxis vs. non-prophylaxis groups; the relative risk reduction was 43%. In the 3 studies that compared corticosteroids to placebo, the relative risk reductions were 25%, 67%, and 72%. The most common treatment regimen was oral dexamethasone at 8 mg once daily from the first day of radiotherapy for 5 days. One study administered methylprednisolone. No severe toxicity was reported in any of the studies. Conclusions Overall, the findings of this systematic review indicate that glucocorticoids appear to be an effective prophylactic treatment to prevent pain flare in patients undergoing radiotherapy for bone metastases. New CT are needed to confirm these results and to determine the optimal dose of dexamethasone.