Recommended Dexamethasone Dosing for COVID-19
The recommended dose of dexamethasone for COVID-19 is 6 mg once daily (oral or IV) for up to 10 days in patients requiring supplemental oxygen or mechanical ventilation. 1, 2
Patient Selection for Dexamethasone Therapy
Dexamethasone therapy should be administered based on COVID-19 severity:
Indicated for:
- Patients requiring supplemental oxygen
- Patients on non-invasive ventilation
- Patients on mechanical ventilation
Not recommended for:
- Patients who don't require supplemental oxygen 1
Dosing Recommendations
Standard Dosing
- Loading dose: None required
- Maintenance dose: 6 mg once daily
- Route: Oral or intravenous
- Duration: Up to 10 days 1, 2
Important Considerations
Do not exceed standard dosing: Higher doses of dexamethasone (20 mg) have been associated with increased mortality in patients requiring high-flow oxygen or non-invasive ventilation 3
Do not extend treatment duration: Extended duration of dexamethasone beyond 10 days is associated with significantly higher in-hospital mortality (36.5% vs 28.5%) compared to the standard 10-day course 4
Avoid duplicate steroid therapy: Patients already receiving prednisolone for COPD exacerbation do not require additional dexamethasone unless they develop COVID-19-related oxygen requirements beyond their baseline needs 1
Evidence Supporting the 6 mg Dose
The 6 mg dose recommendation is based on the landmark RECOVERY trial, which demonstrated:
- 35% reduction in 28-day mortality in patients on invasive mechanical ventilation (29.0% vs. 40.7%)
- 20% reduction in 28-day mortality in patients on supplemental oxygen (21.5% vs. 25.0%)
- No benefit in patients not requiring respiratory support 1, 2
Alternative Approaches That Should Be Avoided
Higher doses (12 mg): A randomized trial comparing 12 mg vs 6 mg of dexamethasone did not show statistically significant improvement in days alive without life support at 28 days 5
Weight-based dosing: While a preliminary study suggested potential benefits of predicted body weight-based dosing, this approach lacks robust evidence compared to the fixed 6 mg dose established in large randomized trials 6
Monitoring During Treatment
Monitor patients on dexamethasone for common adverse effects:
- Hyperglycemia
- Hypokalemia
- Secondary infections (including fungal)
- Hypertension
- Delayed viral clearance 1
Special Considerations
Consider adding tocilizumab in patients who are progressing despite dexamethasone treatment 1
If dexamethasone is unavailable, alternative corticosteroids may be considered:
- Methylprednisolone
- Hydrocortisone 1
The evidence clearly supports using the 6 mg daily dose of dexamethasone for 10 days as the optimal regimen for COVID-19 patients requiring oxygen support, with higher doses and extended duration associated with potential harm.