Glucocorticoids for pain flare prophylaxis after palliative radiotherapy for bone metastases: a systematic review and meta-analysis of randomised controlled trials

Introduction Bone metastases (BMs) are a major cause of cancer-related pain. Palliative radiotherapy is effective for controlling these symptoms, but up to 40% of patients experience transient exacerbations of bone pain despite this. Glucocorticoids have been investigated for pain flare (PF) prophylaxis, but randomised controlled trials (RCTs) have yielded mixed results. The goal of this systematic review and meta-analysis was to analyse the pooled efficacy of glucocorticoids for PF prophylaxis after palliative radiotherapy to BMs. Methods The PubMed, EMBASE and Cochrane CENTRAL databases were systematically searched from inception until August 2024. RCTs that compared PF incidence after radiotherapy to BMs in patients who received prophylaxis with glucocorticoids versus placebo were included. Meta-analyses were conducted using a Mantel-Haenszel random effects model. Risk-of-bias was assessed using the Cochrane Risk of Bias 2 tool. Results We included four RCTs with a total of 765 patients. Three trials compared dexamethasone with placebo, while one trial compared methylprednisolone with placebo. Pooled analysis showed significantly reduced PF incidence after glucocorticoid prophylaxis (risk ratio: 0.59 (95% CI: 0.35 to 0.98), risk difference=−0.13 (95% CI: −0.24 to −0.02)). Study quality assessment indicated that two studies had a low risk of bias, while the other two had moderate and high risk, respectively. Conclusion Current randomised evidence supports the efficacy of glucocorticoid prophylaxis for the prevention of PFs in patients with BMs after the receipt of palliative radiation. Clinicians may consider this intervention to improve patient quality of life and symptom control.