To what extent does dexamethasone (corticosteroid) increase blood pressure (hypertension)?

Dexamethasone's Effect on Blood Pressure

Dexamethasone significantly increases blood pressure, with systolic increases of approximately 6-13 mmHg and diastolic increases of 7-11 mmHg, occurring within the first 48 hours of administration and persisting throughout treatment. 1

Mechanism and Magnitude of Blood Pressure Elevation

• Dexamethasone is listed as a systemic corticosteroid that can increase blood pressure according to the 2017 ACC/AHA hypertension guidelines 2
• In studies of healthy subjects, dexamethasone administration (8 mg/day for 5 days) increased systolic blood pressure by approximately 6 mmHg and diastolic blood pressure by 7 mmHg 1
• Other synthetic glucocorticoids showed similar effects: prednisolone (40 mg/day) increased systolic BP by 13 mmHg and diastolic by 8 mmHg; methylprednisolone (32 mg/day) increased systolic BP by 9 mmHg and diastolic by 11 mmHg 1
• The hypertensive effect occurs independently of mineralocorticoid activity or plasma volume expansion 1

Time Course of Blood Pressure Changes

• Blood pressure elevation begins rapidly, with significant increases observed within the first 48 hours of dexamethasone administration 3
• In premature infants treated with dexamethasone, systolic pressure increased from 51 ± 9.5 mmHg before treatment to 64 ± 10.2 mmHg during therapy (p < 0.01) 3
• Diastolic pressure similarly increased from 29 ± 6.7 mmHg before therapy to 41 ± 8.2 mmHg during therapy (p < 0.01) 3
• Blood pressure elevation persists throughout treatment and may not return to baseline levels after therapy completion 3

Clinical Implications and Risk Factors

• The 2017 ACC/AHA hypertension guidelines recommend limiting or discontinuing systemic corticosteroids when possible in patients with hypertension 2
• Patients with pre-existing hypertension may be more susceptible to dexamethasone-induced blood pressure elevation 3
• In a study of patients with essential hypertension, dexamethasone (0.5 mg three times daily) actually reduced diastolic blood pressure from 104 ± 5 to 96 ± 8 mmHg, suggesting complex interactions in patients with established hypertension 4
• Higher doses of dexamethasone (such as those used in cancer treatment) may cause more pronounced blood pressure elevation 2

Cardiovascular Biomarkers and Other Effects

• Beyond blood pressure elevation, dexamethasone also affects other cardiovascular parameters:
  • Decreases resting heart rate 5
  • Increases B-type natriuretic peptide 5
  • Increases high-density-lipoprotein-cholesterol 5
  • Decreases high-sensitivity C-reactive protein (anti-inflammatory effect) 5
  • Decreases aldosterone levels 5
  • May attenuate nitroglycerin-mediated vasodilatation 5

Management Considerations

• The FDA label for dexamethasone warns that "average and large doses of cortisone or hydrocortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium" 6
• These effects are less likely to occur with synthetic derivatives like dexamethasone except when used in large doses 6
• For patients requiring dexamethasone who develop hypertension, consider:
  • Monitoring blood pressure regularly, especially within the first 48 hours of treatment 3
  • Dietary salt restriction may be necessary 6
  • Potassium supplementation may be required 6
  • Antihypertensive therapy may need to be initiated or intensified 2

Special Populations

• In Cushing's disease, where endogenous glucocorticoid excess occurs, dexamethasone is paradoxically used in low doses to treat glucocorticoid-remediable primary aldosteronism (familial hyperaldosteronism type 1) 2
• In premature infants, dexamethasone causes marked elevation of systolic blood pressure regardless of postnatal age, requiring regular blood pressure monitoring 7
• Patients with pre-existing cardiovascular disease require careful monitoring when receiving dexamethasone 6

Conclusion

Dexamethasone consistently increases blood pressure through glucocorticoid effects that are independent of mineralocorticoid activity. The effect begins rapidly (within 48 hours), persists throughout treatment, and may not fully resolve after discontinuation. Regular blood pressure monitoring is essential for patients receiving dexamethasone, particularly those with pre-existing hypertension or cardiovascular risk factors.