What is the recommended dose of Decadron (dexamethasone) for COVID-19?

Recommended Dexamethasone Dosing for COVID-19

The standard recommended dose of dexamethasone for COVID-19 is 6 mg once daily (oral or IV) for 10 days in patients requiring supplemental oxygen, non-invasive ventilation, or mechanical ventilation. 1

Patient Selection for Dexamethasone Therapy

Dexamethasone therapy should be initiated based on oxygen requirements:

• Recommended for:

  • Patients requiring supplemental oxygen
  • Patients requiring non-invasive ventilation
  • Patients requiring mechanical ventilation 2, 1

• Not recommended for:

  • Non-hospitalized patients with COVID-19
  • Hospitalized patients not requiring oxygen therapy 2, 1

The European Respiratory Society strongly recommends against offering corticosteroids to patients with COVID-19 requiring hospitalization but not requiring supplementary oxygen or ventilatory support, as there is no mortality benefit and potential harm in this group (rate ratio 1.19,95% CI 0.92-1.55) 2, 3.

Evidence Supporting the Standard Dose

The 6 mg daily dexamethasone regimen is based primarily on the RECOVERY trial, which demonstrated:

• 35% reduction in 28-day mortality in patients on invasive mechanical ventilation (29.0% vs. 40.7%, RR = 0.65)
• 20% reduction in 28-day mortality in patients on supplemental oxygen (21.5% vs. 25.0%, RR = 0.80) 1, 3

The pooled effect estimate from multiple studies showed an odds ratio of 0.80 (95% CI 0.64-1.01) for mortality benefit with corticosteroids 2.

Alternative Corticosteroid Options

If dexamethasone is unavailable, other corticosteroids may be considered:

• Methylprednisolone (OR 0.48,95% CI 0.16-1.46)
• Hydrocortisone (OR 0.67,95% CI 0.35-1.29) 2

The test for subgroup analysis did not show significant differences between different corticosteroids (p=0.46), suggesting a class effect 2.

Higher vs. Standard Dose Considerations

Recent evidence has explored higher dexamethasone dosing:

• A randomized trial comparing 12 mg vs. 6 mg of dexamethasone in patients with severe hypoxemia found a non-statistically significant increase in days alive without life support (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = 0.07) 4

• Another trial comparing high-dose (20 mg for 5 days, followed by 10 mg for 5 days) vs. low-dose (6 mg for 10 days) found reduced clinical worsening within 11 days in the high-dose group (16.3% vs. 31.4%, rate ratio 0.427,95% CI 0.216-0.842; p=0.014), but no difference in 28-day mortality 5

Despite these findings, the standard 6 mg dose remains the recommended regimen as higher doses have not consistently demonstrated mortality benefits and may increase risks of adverse effects 1.

Combination Therapy

Consider adding tocilizumab in patients who are progressing despite corticosteroid treatment, as this combination has been shown to reduce disease progression and mortality 2, 1.

Monitoring and Adverse Effects

Monitor patients on dexamethasone for:

• Hyperglycemia
• Hypokalemia
• Secondary infections, including invasive fungal infections
• Hypertension
• Delayed viral clearance 1

Duration of Therapy

The standard duration is 10 days based on the RECOVERY trial protocol. Extended courses beyond 10 days are not recommended as they may be associated with increased in-hospital mortality 1.