What is the Dexamethasone (Decadron) protocol for COVID-19?

From the Guidelines

Dexamethasone (Decadron) is recommended for hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation, with a standard protocol of 6 mg once daily for up to 10 days or until hospital discharge, whichever comes first, as supported by the most recent and highest quality study 1. The use of dexamethasone in COVID-19 patients is based on its ability to reduce the inflammatory response that causes lung damage in severe cases, as demonstrated in the UK RECOVERY trial, which showed a statistically significant reduction in mortality with corticosteroid treatment in patients receiving invasive mechanical ventilation or supplementary oxygen 1. Key points to consider when using dexamethasone for COVID-19 include:

• The medication should only be used in hospitalized patients requiring supplemental oxygen or mechanical ventilation, as it may be harmful in non-hospitalized patients or those not requiring oxygen 1.
• The standard dose is 6 mg once daily, which can be administered orally or intravenously with equivalent effectiveness 1.
• Dexamethasone should be started within 7 days of symptom onset for optimal benefit, and patients should be monitored for potential side effects such as hyperglycemia, secondary infections, psychiatric effects, and gastrointestinal issues 1.
• Other corticosteroids like methylprednisolone or prednisone can be substituted at equivalent doses if dexamethasone is unavailable, although the evidence for these alternatives is not as strong as for dexamethasone 1. It is essential to note that the evidence for dexamethasone in COVID-19 is based on moderate to high-quality studies, with the UK RECOVERY trial being the most significant and influential study to date 1. While other studies, such as the ECIL 9 guidelines, provide additional recommendations for the management of COVID-19 in specific patient populations, the use of dexamethasone in hospitalized patients requiring supplemental oxygen or mechanical ventilation remains the most well-established and widely accepted treatment approach 1.

From the Research

Dexamethasone Protocol for COVID-19

• The current recommended dose of dexamethasone for patients with severe or critical COVID-19 is 6 mg per day for up to 10 days 2.
• However, some studies have investigated the use of higher doses of dexamethasone, such as 12 mg per day 3 or 20 mg per day 4, 5.
• The REMED trial is a prospective, open-label, randomized controlled trial that is testing the superiority of dexamethasone 20 mg vs 6 mg administered once daily intravenously for 10 days in adult patients with moderate or severe ARDS due to confirmed COVID-19 4.
• The COVID STEROID 2 trial found that 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days 3.
• A randomized clinical trial found that dexamethasone 20 mg daily did not result in better clinical outcome improvement, and was probably associated with higher 28-day mortality in patients on high-flow oxygen or noninvasive ventilation, compared with dexamethasone 6 mg daily 5.
• A retrospective cohort study found that early initiation of dexamethasone was associated with higher discharge rates, while late initiation and higher doses were linked to increased mortality 6.

Key Findings

• The use of dexamethasone in patients with COVID-19 has been shown to reduce 28-day mortality among those receiving invasive mechanical ventilation or oxygen alone at randomization 2.
• The timing of dexamethasone initiation has been found to impact outcomes, with earlier use potentially improving mortality and ICU stays 6.
• Higher doses of dexamethasone (>6 mg) have been associated with increased mortality 6.
• Intravenous administration of dexamethasone has been associated with higher mortality 6.

Dosing Regimens

• 6 mg per day for up to 10 days: recommended dose for patients with severe or critical COVID-19 2.
• 12 mg per day: investigated in the COVID STEROID 2 trial, but did not result in statistically significantly more days alive without life support at 28 days 3.
• 20 mg per day: investigated in the REMED trial and a randomized clinical trial, but did not result in better clinical outcome improvement and was associated with higher 28-day mortality in some patients 4, 5.