How to administer Decadron (dexamethasone)?

How to Administer Dexamethasone (Decadron)

Dexamethasone can be administered intravenously (IV), intramuscularly (IM), orally (PO), subcutaneously (SC), or via specialized routes (intra-articular, intralesional, soft tissue injection), with dosing ranging from 0.5 to 9 mg daily for standard indications, though higher doses up to 40 mg are used for specific conditions. 1

Routes of Administration

Intravenous (IV) Administration

• Can be given as direct IV push from the vial or diluted in normal saline or dextrose solution for IV infusion 1
• For slow IV infusion: if perineal burning occurs during administration, decrease the infusion rate or temporarily pause 2
• When diluted in infusion solutions, use within 24 hours as these solutions lack preservatives 1
• Use preservative-free solutions in neonates, especially premature infants 1

Intramuscular (IM) Administration

• Recognize that IM absorption is slower than IV, which may delay therapeutic effect 1
• Standard IM doses range from 0.5 to 9 mg daily, with higher doses (up to 40 mg) for specific indications like immune thrombocytopenic purpura 1, 2

Oral (PO) Administration

• Oral and IV dexamethasone have equivalent 1:1 dosing (e.g., 8 mg IV = 8 mg PO) 3
• Can use either route interchangeably without dose adjustment 3
• Injectable dexamethasone solution can be administered orally when IV access is unavailable 3

Subcutaneous (SC) Administration

• Mentioned as an alternative route in palliative care settings 4

Specialized Injection Routes

• Intra-articular, intralesional, and soft tissue injections: typical single doses range from 0.2 to 6 mg 1
• Frequency ranges from once every 3-5 days to once every 2-3 weeks 1
• Frequent intra-articular injection may damage joint tissues 1

Indication-Specific Dosing

Cerebral Edema

• Initial dose: 10 mg IV, followed by 4 mg IM or IV every 6 hours until symptoms subside 1
• Response typically occurs within 12-24 hours 1
• Reduce dose after 2-4 days and gradually discontinue over 5-7 days 1
• For recurrent/inoperable brain tumors: maintenance of 2 mg two to three times daily 1

Malignant Bowel Obstruction (Palliative Care)

• Dose: 4-12 mg IV daily 4
• Discontinue if no improvement within 3-5 days 4

Bacterial Meningitis

• Administer dexamethasone with or before the first antibiotic dose 4
• Can still initiate up to 4 hours after first antibiotic dose 4
• Consider discontinuing if pathogens other than S. pneumoniae or H. influenzae are identified 4
• Do NOT use in Listeria meningitis—associated with increased mortality 4

COVID-19 (Hospitalized Patients)

• Dose: 6 mg once daily (oral or IV) for up to 10 days 5
• Reduces 28-day mortality in patients requiring oxygen or mechanical ventilation 5
• No benefit (potential harm) in patients not requiring respiratory support 5

Acute Respiratory Distress Syndrome (ARDS)

• Days 1-5: 20 mg IV once daily 6
• Days 6-10: 10 mg IV once daily 6
• Reduces duration of mechanical ventilation and mortality in moderate-to-severe ARDS 6

Chemotherapy-Induced Nausea/Vomiting

• High emetic risk: 12 mg PO/IV on day 1, then 8 mg daily on days 2-3 or 2-4 3
• Moderate emetic risk: 8 mg PO/IV on day 1, then 8 mg daily on days 2-3 3
• Low emetic risk: single 8 mg PO/IV dose 3

Immune Thrombocytopenic Purpura

• Dose: 40 mg daily (IV or PO equivalent) 2
• Consider antifungal prophylaxis with prolonged steroid use 2

Dosing Principles

General Guidelines

• Dosing must be individualized based on disease severity and patient response 1
• Initial doses range from 0.5 mg (mild disease) to >9 mg (severe disease) daily 1
• In life-threatening situations, doses may be multiples of standard oral dosing 1
• Maintain initial dose until satisfactory response, then taper to lowest effective maintenance dose 1

Tapering Protocol

• For doses ≥8 mg/day used >5 days: reduce by 50% every 3-4 days until reaching 4 mg/day, then by 2 mg every 3-4 days until 2 mg/day, finally by 1 mg every 3-4 days until discontinued 3
• Gradual withdrawal is essential after more than a few days of treatment 1
• Monitor for withdrawal symptoms at each tapering step 3

Critical Safety Considerations

Administration Precautions

• Inspect solution for particulate matter and discoloration before administration 1
• Observe sterile technique when mixing with infusion solutions 1

Monitoring Requirements

• Watch for signs requiring dose adjustment: disease exacerbations/remissions, individual drug responsiveness, stress (surgery, infection, trauma) 1
• May need temporary dose increase during stress periods 1

Common Pitfalls to Avoid

• Do NOT confuse dexamethasone with other corticosteroids that have different oral-to-IV conversion ratios 3
• Do NOT adjust dose when converting between oral and IV dexamethasone formulations 3
• Do NOT use in Listeria meningitis—stop immediately if identified 4
• Do NOT use in COVID-19 patients without oxygen requirement—may increase mortality 5
• Avoid frequent intra-articular injections—causes joint damage 1

Adverse Effects to Monitor

• Peptic ulceration may occur with high-dose, short-term therapy (48-72 hours) 1
• Posterior subcapsular cataracts can develop even with short-term intermittent use 7
• Hyperglycemia is common (70-76% of ICU patients) 6
• New infections occur in approximately 24-25% of patients 6