What are the contraindications to dexamethasone (corticosteroid) use?

Contraindications to Dexamethasone Use

Dexamethasone is contraindicated in patients with systemic fungal infections, active tuberculosis (unless used with appropriate antitubercular regimens), and history of anaphylactic reactions to the drug or its components. 1, 2

Absolute Contraindications

• Systemic fungal infections: Dexamethasone may exacerbate these infections 1, 2
• Hypersensitivity: History of anaphylactic reactions to dexamethasone or any of its components 1
• Live virus vaccines: Administration of live virus vaccines is contraindicated in individuals receiving immunosuppressive doses of corticosteroids 2
• Epidural administration: Not approved for epidural use due to reports of serious neurological events including spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke 2

Relative Contraindications and Precautions

Infections

• Tuberculosis: Use should be restricted to cases of fulminant or disseminated tuberculosis where dexamethasone is used in conjunction with appropriate antitubercular regimens 1, 2
• Latent amebiasis: Should be ruled out before initiating therapy, especially in patients who have spent time in the tropics or have unexplained diarrhea 2
• Immunosuppression: Caution in patients with primary or acquired immunodeficiency, including HIV/AIDS 1

Medical Conditions

• Diabetes: Exercise caution as dexamethasone may increase blood glucose levels and requirements for insulin or oral hypoglycemic agents 2
• Hypertension: May cause elevation of blood pressure, salt and water retention 2
• Recent myocardial infarction: Associated with left ventricular free wall rupture 2
• Gastrointestinal conditions: Risk of peptic ulcer disease, especially with concomitant NSAID use 3
• Ocular conditions: Prolonged use may lead to posterior subcapsular cataracts, glaucoma, and secondary ocular infections 2

Special Populations

• Pregnancy: Should be used with caution as it may affect the fetus 2
• Breastfeeding: Mothers taking pharmacologic doses of corticosteroids should be advised not to breastfeed 2
• Children: May suppress growth 2

Precautions in Specific Clinical Scenarios

COVID-19 Treatment

In COVID-19 treatment, clinicians should exercise caution when using dexamethasone in:

• Patients with diabetes or underlying immunocompromise 3
• Populations under-represented in trials, such as children and immunocompromised patients 3

Cancer Immunotherapy

When using dexamethasone for management of immune-related adverse events:

• Consider infection workup before initiating treatment 3
• Be aware of potential complications including hyperglycemia and hyponatremia 3

Bacterial Meningitis

• Dexamethasone is not recommended for neonatal meningitis 3
• Should be started with the first dose of antibiotics or within 4 hours of antibiotic initiation 3

Monitoring and Management

When dexamethasone must be used despite relative contraindications:

1. Assess infection risk: Consider prophylactic antibiotics/antifungals in high-risk patients
2. Monitor for metabolic effects: Regular blood glucose monitoring and electrolyte checks
3. Taper appropriately: Avoid abrupt discontinuation to prevent adrenal insufficiency
4. Consider lowest effective dose: Use the minimum dose needed for the shortest duration possible

Conclusion

When evaluating whether to use dexamethasone, clinicians must carefully weigh the potential benefits against risks, particularly in patients with infections, diabetes, or immunosuppression. In many cases, the life-saving benefits of short-term dexamethasone may outweigh the risks, but close monitoring and appropriate precautions are essential.