What are the indications and dosing guidelines for dexamethasone?

Dexamethasone: Indications and Dosing Guidelines

Dexamethasone is a potent synthetic corticosteroid with diverse clinical applications, with dosing regimens that vary significantly based on the specific indication, patient factors, and desired therapeutic effect. 1, 2

Key Indications and Dosing Regimens

Immunotherapy-Related Toxicities

• Cytokine Release Syndrome (CRS):

  • Grade 1: 10 mg IV q24h for early-onset CRS (<72 hours after CAR T-cell infusion) 3
  • Grade 2: 10 mg IV q12-24h for persistent refractory hypotension 3
  • Grade 3-4: 10 mg IV q6h 3

• Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS):

  • Grade 1: Consider 10 mg IV q12-24h for 2 doses if within 72h of CAR T-cell infusion 3
  • Grade 2: 10 mg IV, may repeat q6-12h if no improvement 3
  • Grade 3: 10 mg IV q6h 3
  • Grade 4: High-dose corticosteroids (methylprednisolone 1000 mg/day) 3

Chemotherapy-Induced Nausea and Vomiting (CINV)

• High emetic risk chemotherapy:
  • With NK1 antagonist: 12 mg oral/IV on day 1, then 8 mg oral/IV on days 2-3 or 2-4 3
  • With fosaprepitant: 12 mg oral/IV on day 1, then 8 mg oral/IV on day 2, followed by 8 mg oral/IV twice daily on days 3-4 3
• Moderate emetic risk: 8 mg oral/IV on day 1, then 8 mg on days 2-3 3
• Low emetic risk: Single 8 mg oral/IV dose 3

Bacterial Meningitis

• Adults: 0.15 mg/kg IV q6h for 2-4 days, with first dose 10-20 min before or with first antimicrobial dose 3
• Children ≥6 weeks: 0.15 mg/kg IV q6h for 2-4 days 1

Acute Respiratory Distress Syndrome (ARDS)

• 20 mg IV once daily for 5 days, then 10 mg once daily for 5 days 4

COVID-19

• 6 mg IV/oral once daily for up to 10 days (standard dose) 5, 6
• Higher doses (>10 mg daily) have not shown mortality benefit and are associated with higher blood glucose levels and longer ICU stays 6

Cerebral Edema

• Initial: 10 mg IV, followed by 4 mg IV q6h until symptoms subside 2
• For brain tumors: Maintenance with 2 mg two to three times daily 2

Acute Allergic Disorders

• First day: 4-8 mg IM, followed by oral tapering dose 2

Perioperative Use

• 8 mg single dose for prevention of postoperative nausea and vomiting 3
• 0.15 mg/kg (minimum 2-4 mg) for post-tonsillectomy pain and nausea/vomiting 1

Multiple Myeloma

• Dosing varies by regimen, typically 20-40 mg weekly or in divided doses 3

Administration Routes and Considerations

• Routes: IV, IM, oral, intra-articular, intralesional, soft tissue injection 2
• Intra-articular dosing:
  • Large joints (e.g., knee): 2-4 mg
  • Small joints: 0.8-1 mg
  • Bursae: 2-3 mg
  • Tendon sheaths: 0.4-1 mg 2

Important Clinical Considerations

• Tapering: For treatment courses >few days, gradual tapering is recommended to prevent adrenal insufficiency 2
• Monitoring: Patients should be monitored for hyperglycemia, hypertension, infection risk, and other corticosteroid-related adverse effects 1
• Contraindications: Systemic fungal infections, known hypersensitivity 1
• Special populations: Use with caution in patients with diabetes due to effects on glucose metabolism 1

Dosing Adjustments

• Stress situations (surgery, infection, trauma): May require temporary dose increases 2
• Shock: Various high-dose regimens have been suggested, ranging from 1 mg/kg as a single IV injection to 3 mg/kg/24h by constant IV infusion 2

Dexamethasone's high potency (approximately 4 mg dexamethasone = 20-25 mg prednisone) and excellent CNS penetration make it particularly valuable for conditions requiring CNS effects or shorter treatment courses 1.

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