Recommended Dexamethasone Dosing in Multiple Myeloma
The standard dose of dexamethasone in multiple myeloma is 40 mg orally weekly (days 1,8,15,22) in a 28-day cycle, or 20 mg on the day of and day after proteasome inhibitor administration in combination regimens. 1
Standard Dosing Regimens
- For lenalidomide-based regimens (Rd): Dexamethasone 40 mg orally on days 1,8,15, and 22 of a 28-day cycle 1
- For bortezomib-based combinations (VCD): Dexamethasone 40 mg orally on days 1,8,15, and 22 of a 28-day cycle 1
- For bortezomib/thalidomide combinations (VTD): Dexamethasone 20 mg on day of and day after bortezomib (or alternatively 40 mg on days 1,8,15,22) 1
- For bortezomib/lenalidomide combinations (VRd): Dexamethasone 20 mg on day of and day after bortezomib (or alternatively 40 mg on days 1,8,15,22) in a 21-day cycle 1, 2
Dosing in Relapsed/Refractory Setting
- For carfilzomib/lenalidomide combinations (KRd): Dexamethasone 40 mg on days 1,8,15,22 of a 28-day cycle 1
- For carfilzomib/dexamethasone (Kd): Dexamethasone 20 mg on days 1,2,8,9,15,16,22,23 of a 28-day cycle 1
- For pomalidomide-based regimens: Dexamethasone 40 mg weekly in a 28-day cycle 1, 3
- For daratumumab combinations: Dexamethasone dosing varies by regimen but typically follows the partner drug schedule 1
Clinical Considerations
- Three-drug combinations that include dexamethasone and bortezomib are currently the standard of care for induction therapy before autologous stem cell transplantation 1
- The VTD (bortezomib/thalidomide/dexamethasone) and VCD (bortezomib/cyclophosphamide/dexamethasone) regimens are preferred in Europe, while RVD (lenalidomide/bortezomib/dexamethasone) is widely used in the United States 1
- Four to six courses of induction therapy are recommended before proceeding to stem cell collection 1
Toxicity Management
- Common toxicities of dexamethasone include hyperglycemia, insomnia, gastric irritation, fluid retention, and mood changes 1
- For patients experiencing significant steroid-related side effects, consider dose reduction rather than complete discontinuation to maintain efficacy 1
- Elderly patients or those with comorbidities may benefit from lower doses (e.g., 20 mg weekly) to reduce toxicity while maintaining efficacy 1
Special Populations
- For patients over 75 years of age, consider lower doses of dexamethasone to minimize toxicity 1
- For patients with diabetes, close monitoring of blood glucose levels and adjustment of antidiabetic medications may be necessary 1
- For patients with a history of psychiatric disorders, careful monitoring for mood changes is recommended 1
Evidence Quality
- The recommended dosing regimens are based on phase III clinical trials that have demonstrated improved progression-free survival and overall survival 1, 2
- The ESMO clinical practice guidelines provide the strongest evidence for these dosing recommendations 1
- Recent NCCN guidelines (2023) continue to support these dosing strategies for both newly diagnosed and relapsed/refractory multiple myeloma 1