What is the recommended dose of dexamethasone (corticosteroid) for treating vestibular neuritis?

Dexamethasone Dosing for Vestibular Neuritis

For vestibular neuritis, dexamethasone should be administered at a dose of 10 mg/day orally for 5 days, followed by a tapering dose over the next 5 days. 1

Recommended Corticosteroid Regimen

Initial Treatment

• Oral dexamethasone 10 mg/day for 5 days 1
• For patients with severe nausea, consider initial intravenous dexamethasone 8 mg for 1-2 days before transitioning to oral therapy 2, 3
• Treatment should be initiated as soon as possible, ideally within the first 24 hours of symptom onset, as earlier treatment leads to better vestibular function recovery 2

Tapering Schedule

• After 5 days of full-dose therapy, taper the dose over the next 5 days 1, 3
• A typical tapering schedule would reduce the dose by approximately 2 mg every 1-2 days 1

Evidence Supporting Corticosteroid Use

• Corticosteroid treatment significantly improves long-term recovery of vestibular function compared to no treatment (70% vs 34% normal caloric test results at follow-up) 3
• Patients treated within 24 hours of symptom onset show better outcomes, with 100% achieving normal caloric test results at 3-month follow-up compared to 58% of those treated between 25-72 hours 2
• Meta-analysis shows that steroid treatment results in better recovery than control therapies with a number needed to treat (NNT) of 6 in the acute phase 4

Alternative Corticosteroid Options

• If dexamethasone is unavailable, equivalent alternatives include:
  • Prednisone 60 mg/day (1 mg/kg/day, max 60 mg) for 5 days, then taper 1
  • Methylprednisolone 48 mg/day for 5 days, then taper 1
  • Note that dexamethasone is 25 times more potent than hydrocortisone, while prednisone is 4 times and methylprednisolone is 5 times more potent 1

Important Clinical Considerations

• Early treatment is crucial - initiate therapy as soon as possible after diagnosis, ideally within 24 hours 2, 5
• Hospitalization may be required for patients with severe symptoms, but corticosteroid treatment can reduce length of hospital stay (1.8 vs 3.0 days) 3
• Recovery from vestibular neuritis occurs through a combination of peripheral restoration of labyrinthine function (improved by corticosteroids), sensory substitution, and central compensation 5
• Monitor for common adverse effects of short-term corticosteroid use, including hyperglycemia and sleep disturbances 1

Pitfalls and Caveats

• Underdosing is a common pitfall - ensure adequate initial dosing for maximum benefit 1
• The commonly prescribed methylprednisolone dose pack (4 mg tablets with decreasing doses over 6 days) provides insufficient total corticosteroid exposure compared to the recommended regimen 1
• While serious side effects are rare with short-term corticosteroid use, patients should be monitored for adverse effects, particularly those with pre-existing conditions such as diabetes 1
• Treatment benefits diminish when initiated after 72 hours from symptom onset, though some benefit has been reported up to 6 weeks 1, 5