Can steroids like dexamethasone be prescribed to a mesothelioma patient with elevated C-reactive protein (CRP) and normal white blood cell (WBC) and neutrophil counts, who is already on antibiotics (tazocin and clarithromycin), to boost mood and appetite, and is zopiclone suitable for sleep disturbances?

Steroid Use in Mesothelioma Patients with Elevated CRP

Dexamethasone 8-10mg IV/PO daily can be safely prescribed to boost mood and appetite in a mesothelioma patient with elevated CRP, even while on antibiotics, as the CRP elevation may be cancer-related rather than infectious. 1, 2

Understanding CRP Elevation in Mesothelioma

Elevated CRP in a mesothelioma patient with normal WBC and neutrophil counts is more likely related to the underlying malignancy rather than infection. This is particularly true when:

• Minimal infective symptoms are present
• WBC and neutrophil counts remain normal
• Patient is already on appropriate antibiotic therapy (tazocin and clarithromycin)

Cancer itself can cause inflammatory responses leading to elevated CRP levels, as malignant cells release pro-inflammatory cytokines 3.

Steroid Recommendations

Dexamethasone for Appetite and Mood

• First-line choice: Dexamethasone 8-10mg IV/PO daily 1
• Rationale: Dexamethasone has minimal mineralocorticoid activity and provides rapid onset of action (within hours) 2
• Duration: Short course of 1-2 weeks with tapering to minimize side effects
• Administration timing: Morning dosing to minimize sleep disturbances

Dexamethasone is specifically recommended in oncology guidelines for symptom management in cancer patients 1. It has been shown to effectively:

• Improve appetite
• Enhance mood
• Reduce fatigue
• Provide anti-emetic effects

Safety with Concurrent Antibiotics

Administering steroids while the patient is on antibiotics (tazocin and clarithromycin) is acceptable because:

1. The patient is already receiving appropriate antibiotic coverage
2. The normal WBC and neutrophil counts suggest the CRP elevation is likely cancer-related
3. Guidelines do not contraindicate steroid use with antibiotics in this context 1

Sleep Management

For sleep disturbances:

• Zopiclone is appropriate for short-term management of insomnia in this patient
• Recommended dosage: 3.75-7.5mg at bedtime
• Duration: Short-term use (2-4 weeks maximum) to avoid dependence
• Precautions: Start with lower dose (3.75mg) in elderly patients or those with hepatic impairment

Monitoring and Precautions

When initiating steroids:

1. Monitor glucose levels regularly as steroids can cause hyperglycemia
2. Watch for mood changes including agitation or euphoria
3. Monitor for gastrointestinal symptoms including potential bleeding
4. Consider gastric protection with a proton pump inhibitor if using steroids for >1 week
5. Taper gradually when discontinuing to avoid adrenal insufficiency

Alternative Approaches

If dexamethasone is not tolerated or contraindicated:

• Methylprednisolone 16-32mg daily can be considered as an alternative
• Prednisolone 20-40mg daily is another option with similar effects

Important Caveats

• Limit steroid duration to minimize immunosuppressive effects
• If clinical deterioration occurs despite antibiotics, reassess for infection progression
• Consider discontinuing steroids if new infection develops
• Avoid abrupt steroid discontinuation; taper gradually

Steroids like dexamethasone can significantly improve quality of life in mesothelioma patients by enhancing appetite and mood, which aligns with prioritizing patient comfort and quality of life in advanced cancer management.