dexamethasone (Decadron, Dexamethasone Intensol, Dexasone, Solurex, Baycadron)

Dosing and uses of Decadron, Dexamethasone Intensol (dexamethasone)

• Adult
• Pediatric

 

Adult dosage forms and strengths

tablet

• 0.5mg
• 0.75mg
• 1mg
• 1.5mg
• 2mg
• 4mg
• 6mg

injectable suspension

• 4mg/mL
• 10mg/mL

elixir/oral solution

• 0.5mg/5mL

oral concentrate

• 1mg/1mL

 

Inflammation

0.75-9 mg/day IV/IM/PO divided q6-12hr

Intra-articular, intralesional, or soft tissue: 0.2-6 mg/day

 

Multiple Sclerosis (Acute Exacerbation)

30 mg/day PO for 1 week; follow by 4-12 mg/day for 1 mo

 

Cerebral Edema

10 mg IV, then 4 mg IM q6hr until clinical improvement is observed; may be reduced after 2-4 days and gradually discontinued over 5-7 days

 

Shock

1-6 mg/kg IV once or 40 mg IV q2-6hr PRn

Alternative: 20 mg IV, then 3 mg/kg/day by continuous IV infusion

High-dose treatment not to be continued beyond 48-72 hours

 

Allergic Conditions

For control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, and serum sickness

Day 1: 4-8 mg Im

Days 2-3: 3 mg/day PO divided q12hr

Day 4: 1.5 mg/day PO divided q12hr

Days 5-6: 0.75 mg/day PO in single daily dose

Day 7: No treatment

 

Dexamethasone Suppression Test

Low-dose test

• Screening for Cushing syndrome
• Overnight test: 1 mg PO between 11:00 PM and midnight; cortisol level tested between 8:00 and 9:00 AM on following morning
• Standard 2-day test: 0.5 mg PO q6hr (9:00 AM, 3:00 PM, 9:00 PM, 3:00 AM) for 2 days; cortisol level tested 6 hours after final dose (9:00 AM)

High-dose test

• Confirmed Cushing syndrome in which further workup is needed to identify whether hormone excess is the result of cushing syndrome or other causes
• Standard 2-day test: After determination of baseline serum cortisol or 24-hr urinary free cortisol, 2 mg PO q6hr for 2 days; urine for free cortisol is collected during test, and serum cortisol is checked 6 hours after final dose
• Overnight test: After determination of baseline serum cortisol, 8 mg (typically) PO between 11:00 pm and midnight; cortisol level tested between 8:00 and 9:00 AM on following morning
• IV test: After determination of baseline serum cortisol, 1 mg/hr by continuous IV infusion for 5-7 hours

 

Chemotherapy-Induced Nausea & Vomiting (Off-label)

8-12 mg PO/IV alone or in combination with other antiemetics before chemotherapy, then 8 mg PO/IV q24hr for 1-3 days after chemotherapy (days 2-4)

 

Altitude Sickness (Off-label)

Prophylaxis

• 2 mg PO q6hr or 4 mg PO q12hr beginning on day of ascent; may be discontinued after 2- to 3-day stay at same elevation or initiation of descent

Treatment

• Acute mountain sickness (AMS): 4 mg PO/IV/IM q6hr
• High-altitude cerebral edema (HACE): 8 mg once followed by 4 mg PO/IV/IM q6hr until symptoms resolve

 

Spinal Cord Compression (Off-label)

10-100 mg IV, then 4-24 mg IV q6hr during radiation therapy, then tapered

 

Pediatric dosage forms and strengths

tablet

• 0.5mg
• 0.75mg
• 1mg
• 1.5mg
• 2mg
• 4mg
• 6mg

injectable suspension

• 4mg/mL
• 10mg/mL

elixir/oral solution

• 0.5mg/5mL

oral concentrate

• 1mg/1mL

 

Airway Edema

0.5-2 mg/kg/day PO/IV/IM divided q6hr, starting 24 hours before extubation and continued for 4-6 doses afterward

 

Croup

0.6 mg/kg PO/IV/IM once; not to exceed 16 mg

 

Inflammation

0.08-0.3 mg/kg/day IV/PO/IM divided q6hr or q12hr

 

Meningitis

>6 weeks: 0.6 mg/kg/day IV divided q6hr for first 2-4 days of antibiotic therapy, starting 10-20 minutes before or simultaneously with first antibiotic dose

 

Cerebral Edema Associated With Brain Tumor

1-2 mg/kg IV/IM once; maintenance: 1-1.5 mg/kg/day IV/IM divided q4-6hr; not to exceed 16 mg/day

 

Spinal Cord Compression

2 mg/kg/day IV divided q6hr

 

Adrenal Cortical Hyperfunction Test

After determination of baseline cortisol level, 1 mg PO at bedtime

Plasma cortisol level then determined at 8:00 AM on following morning; level will be decreased in normal individuals but at baseline level in Cushing syndrome

 

Respiratory Distress Syndrome in Premature Infants (Off-label)

Prophylaxis

4 mg IM q8hr administered to mother for 2 days before delivery

 

Decadron, Dexamethasone Intensol (dexamethasone) adverse (side) effects

Frequency not defined

Acne

Adrenal suppression

Arrhythmia

Bradycardia

Cardiac arrest

Cataracts

Change in spermatogenesis

Delayed wound healing

Depression

Diabetes mellitus

Diaphoresis

Emotional instability

Erythema

Euphoria

Exophthalmos

GI perforation

Glaucoma

Glucose intolerance

Glucosuria

Hepatomegaly

Hypokalemic alkalosis

Increased intracranial pressure

Increased transaminases

Insomnia

Kaposi's sarcoma

Menstrual irregularity

Moon face

Myopathy

Neuritis

Osteoporosis

Peptic ulcer

Perianal pruritus

Petechia

Perianal pruritus

Pituitary adrenal axis suppression

Pseudotumor cerebri (on withdrawal)

Psychosis

Pulmonary edema

Rash

Seizure

Spermatogenesis altered (increased or decreased)

Ulcerative esophagitis

Urticaria

Vertigo

Weight gain

 

Postmarketing Reports

•Fluid and electrolyte disturbances: Tumor lysis syndrome

 

Warnings

Contraindications

Systemic fungal infection

Documented hypersensitivity

Cerebral malaria

Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids

 

Cautions

Use with caution in cirrhosis, diverticulitis, myasthenia gravis, peptic ulcer disease, ulcerative colitis, renal insufficiency, pregnancy

Average and large doses of corticosteroids can cause elevation of blood pressure, sodium and water retention, and increased excretion of potassium; these effects are less likely to occur with synthetic derivatives except when used in large doses; dietary salt restriction and potassium supplementation may be necessary; all corticosteroids increase calcium excretion

Literature reports suggest apparent association between use of corticosteroids and left ventricular free wall rupture after recent myocardial infarction; therapy with corticosteroids should be used with great caution in these patients

Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with potential for glucocorticosteroid insufficiency after withdrawal of treatment; adrenocortical insufficiency may result from too rapid withdrawal; may be minimized by gradual reduction of dosage; relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, reinstitute hormone therapy; if patient is receiving steroids already, may increase dosage

Metabolic clearance of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients; changes in thyroid status of patient may necessitate adjustment in dosage

Corticosteroids may exacerbate systemic fungal infections; not for use in presence of such infections unless needed to control life-threatening drug reactions; concomitant use of amphotericin B and hydrocortisone followed by cardiac enlargement and congestive heart failure reported

Latent disease may be activated or there may be an exacerbation of intercurrent infections due to pathogens, including those caused by Amoeba, Candida, Cryptococcus, Mycobacterium, Nocardia, Pneumocystis, toxoplasma; rule out latent amebiasis or active amebiasis before initiating corticosteroid therapy in any patient who has spent time in the tropics or any patient with unexplained diarrhea

Corticosteroids should be used with great care in patients with known or suspected Strongyloides (threadworm) infestation; corticosteroid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia; not for use in cerebral malaria

Close observation necessary if corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity; reactivation of the disease may occur; during prolonged corticosteroid therapy, these patients should receive chemoprophylaxis

Use of oral corticosteroids not recommended in treatment of optic neuritis and may lead to increase in risk of new episodes; corticosteroids should not be used in active ocular herpes simplex

Use lowest possible dose to control condition under treatment; risk/benefit decision must be made in each individual case as to dose and duration of treatment and as to whether daily or intermittent therapy should be used

May lead to inhibition of bone growth in pediatric patients and development of osteoporosis at any age; special consideration should be given to patients at increased risk of osteoporosis (e.g., postmenopausal women) before initiating corticosteroid therapy

Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations; existing emotional instability or psychotic tendencies may also be aggravated by corticosteroids

Minimal mineralocorticoid activity

Thromboembolic disorders

Myopathy has been reported

Delayed wound healing

Withdraw therapy with gradual tapering dose

May have systemic and local effects; examine joint fluid, as necessary to exclude a septic process; avoid injection into infected site; frequent intra-articular injections may result in damage to joint tissue

If exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated; if exposed to measles, prophylaxis with immune globulin (IG) may be indicated; if chickenpox develops, treatment with antiviral agents should be considered

Latent tuberculosis may be reactivated (patients with positive tuberculin test should be monitored)

Some suggestion (not fully substantiated) of slightly increased cleft palate risk if corticosteroids are used in pregnancy

Prolonged corticosteroid use may result in elevated intraocular pressure, glaucoma, or cataracts; if steroid therapy is continued for more than 6 weeks, monitor intraocular pressure

Prolonged therapy has been associated with development of Karposi sarcoma

May affect velocity growth in children; monitor routinely

Killed or inactivated vaccines may be administered; however, the response to such vaccines cannot be predicted

Patient may requre higher doses when subject to stress

Immunization procedures may be undertaken in patients who are receiving corticosteroids as replacement therapy in physiologic doses (eg, for Addison’s disease)

Epidural injection

• Serious neurologic events, some resulting in death, have been reported with epidural injection
• Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke
• These serious neurologic events have been reported with and without use of fluoroscopy
• Safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use

 

Pregnancy and lactation

Pregnancy category: C

Lactation: Drug excreted in breast milk; not recommended

 

Pregnancy categories

A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA: Information not available.

 

Pharmacology of Decadron, Dexamethasone Intensol (dexamethasone)

Mechanism of action

Potent glucocorticoid with minimal to no mineralocorticoid activity

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and reducing capillary permeability; stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines; suppresses lymphocyte proliferation through direct cytolysis, inhibits mitosis, breaks down granulocyte aggregates, and improves pulmonary microcirculation

 

Absorption

Onset: Between a few minutes and several hours; dependent on indication and route of administration

Peak serum time: 8hr (IM); 1-2 hr (PO)

 

Distribution

Vd: 2 L/kg

 

Metabolism

Metabolized in liver

 

Elimination

Half-life: 1.8-3.5 hr (normal renal function)

Excretion: Urine (mainly), feces (minimally)

 

Administration

IV Compatibilities

Solution: D5W, Ns

Additive: Aminophylline, bleomycin, cimetidine, floxacillin, furosemide, granisetron, lidocaine, meropenem, mitomycin, nafcillin, netilmicin, ondansetron, prochlorperazine, ranitidine, verapamiL

Syringe: Caffeine, granisetron, metoclopramide, ondansetron, ranitidine, sufentaniL

Y-site (partial list): Acyclovir, allopurinol, cisplatin, cladribine, cyclophosphamide, cytarabine, docetaxel, etoposide phosphate, famotidine, fentanyl, fluconazole, gemcitabine, heparin with hydrocortisone, linezolid, lorazepam, meperidine, morphine, potassium chloride, propofol, sodium bicarbonate, zidovudine

 

IV Incompatibilities

Additive: Amikacin(?), daunorubicin, diphenhydramine with lorazepam and metoclopramide, metaraminol, vancomycin

Syringe: Diphenhydramine(?), doxapram, glycopyrrolate, hydromorphone(?)

Y-site: Ciprofloxacin, fenoldopam, idarubicin, methotrexate(?), midazolam, topotecan

 

IV Preparation

Standard diluent: 4 mg/50 mL D5W or 10 mg/50 mL D5W

Minimum volume: 50 mL D5W

Dexamethasone 4 mg/mL injection is clear and colorless

 

IV/IM Administration

Dexamethasone sodium phosphate: Administered by IV push, continuous or intermittent IV infusion, or Im

Acetate injection: Administered only Im

 

Storage

Protect from light

Protect from freezing