Can intravenous (IV) dexamethasone be administered orally in pediatric patients?

From the Guidelines

IV dexamethasone can be administered orally in pediatric patients, but with necessary dosage adjustments and precautions. The oral to IV conversion ratio for dexamethasone is approximately 1:1 due to its high oral bioavailability of about 80-90% 1. When switching from IV to oral administration, it is recommended to maintain the same total daily dose, but divide it into two or three doses per day. For example, if a child was receiving 4 mg IV once daily, you could switch to 2 mg orally twice daily.

Key Considerations

• Oral administration may be preferred in stable patients who can tolerate oral medications, as it's less invasive and often more comfortable for children 1.
• However, in cases of severe illness, inability to tolerate oral medications, or need for rapid effect, IV administration may still be necessary.
• The practice of giving IV formulations orally is sometimes used when oral liquid formulations are unavailable, but it's crucial to check with the hospital pharmacy about the appropriateness of this practice, as some IV formulations may contain additives not suitable for oral consumption.
• Dexamethasone has been shown to have a significant analgesic effect after tonsillectomy when administered alone or in combination with other analgesics, and it consistently reduces the incidence of nausea and vomiting after tonsillectomy 1.

Administration and Monitoring

• When administering dexamethasone orally, it's best given with food to minimize gastrointestinal side effects.
• Monitor the patient closely for signs of adrenal suppression, especially if used long-term, and consider tapering the dose when discontinuing therapy if it has been used for more than a few days.
• The appropriate dose of dexamethasone for analgesia in children is at least 0.15 mg/kg, whereas adult studies used a total of 8 mg or more 1.
• There is no consistent evidence concerning the appropriate dose or a dose-dependent effect for analgesia, but studies showing an analgesic effect in children use a dose of at least 0.15 mg/kg 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dexamethasone sodium phosphate injection, USP 4 mg/mL is for intravenous, intramuscular, intra-articular, intralesional and soft tissue injection. When the intravenous route of administration is used, dosage usually should be the same as the oral dosage

The answer is no, intravenous (IV) dexamethasone cannot be administered orally in pediatric patients, as the label specifies that the IV formulation is for intravenous use, and oral administration is not mentioned as an option for this formulation. 2

From the Research

Administration of IV Dexamethasone Orally in Pediatric Patients

• The study 3 assessed the efficacy of injectable dexamethasone administered orally in pediatric patients with asthma exacerbation, suggesting it may be an efficacious treatment.
• However, the study 4 found that injectable dexamethasone sodium phosphate administered orally is not bioequivalent to dexamethasone oral concentrate, with a relative bioavailability of 87.4% and 91.1% when using AUC(0-t) and AUC(0-∞), respectively.
• The study 5 described factors associated with prescribed dexamethasone in a pediatric emergency department, but did not specifically address the administration of IV dexamethasone orally.
• The study 6 prepared and evaluated the physicochemical stability of liquid oral dosage forms of dexamethasone free of potentially harmful excipients, but did not address the administration of IV dexamethasone orally.
• The study 7 compared the efficacy of a single dose of dexamethasone to 2 doses of dexamethasone in treating mild to moderate asthma exacerbations in pediatric patients, but did not address the administration of IV dexamethasone orally.

Key Findings

• Injectable dexamethasone administered orally may be an efficacious treatment for asthma exacerbation in pediatric patients 3.
• Injectable dexamethasone sodium phosphate administered orally is not bioequivalent to dexamethasone oral concentrate 4.
• Dosing adjustments may be considered when administering injectable dexamethasone orally 4.