What are the uses of dexamethasone?

Dexamethasone: Clinical Uses and Applications

Dexamethasone is a potent synthetic glucocorticoid used primarily for its anti-inflammatory and immunosuppressive properties across multiple clinical conditions, including bacterial meningitis, severe COVID-19, acute respiratory distress syndrome, cancer-related complications, perioperative care, and various inflammatory disorders. 1, 2

Primary Indications

Bacterial Meningitis

• In adults with suspected or proven pneumococcal meningitis, administer dexamethasone 0.15 mg/kg every 6 hours (or 10 mg every 6 hours) for 2-4 days, with the first dose given 10-20 minutes before or concurrent with the first antibiotic dose. 1
• This regimen reduces unfavorable outcomes (26% vs 52%) and mortality (14% vs 34%) specifically in pneumococcal meningitis. 1
• In children beyond the neonatal period, use 0.15 mg/kg every 6 hours for 4 days to significantly reduce hearing loss and neurologic sequelae. 1
• Dexamethasone can be initiated up to 4 hours after antibiotics if not given initially, though earlier administration is preferred. 1
• Stop dexamethasone if the pathogen is identified as neither H. influenzae nor S. pneumoniae. 1

COVID-19 and Acute Respiratory Distress Syndrome

• For hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation, give dexamethasone 6 mg once daily (oral or intravenous) for up to 10 days. 2
• This reduces 28-day mortality in patients on invasive mechanical ventilation (29.3% vs 41.4%) and those on oxygen without ventilation (23.3% vs 26.2%). 2
• Do not use dexamethasone in COVID-19 patients not requiring respiratory support, as it may increase mortality (17.8% vs 14.0%). 2
• For moderate-to-severe ARDS, administer 20 mg intravenously once daily for days 1-5, then 10 mg once daily for days 6-10, which increases ventilator-free days by 4.8 days and reduces 60-day mortality from 36% to 21%. 3
• Dexamethasone reduces airway flooding by activating ENaC sodium channels and inhibiting CFTR chloride channels, decreasing airway surface liquid volume. 4

Oncologic Applications

CAR T-Cell Therapy Complications

• For grade 2 immune effector cell-associated neurotoxicity syndrome (ICANS), give one dose of dexamethasone 10 mg IV and reassess; repeat every 6-12 hours if no improvement. 1
• For grade 3-4 ICANS, administer dexamethasone 10 mg IV every 6 hours or methylprednisolone 1 mg/kg IV every 12 hours. 1
• ICU care with mechanical ventilation for airway protection is recommended for grade 3-4 neurotoxicity. 1

Acute Lymphoblastic Leukemia

• Dexamethasone is a backbone component of induction therapy, significantly decreasing CNS relapse risk and improving event-free survival compared to prednisone. 1
• The COG protocol uses 6 mg/m² per day for 28 days during induction. 1
• Dexamethasone provides superior CNS penetration compared to prednisone, reducing isolated CNS relapse (RR 0.53). 1
• Monitor closely for toxicities including osteonecrosis, infection, neuropsychiatric events (RR 4.55), and myopathy (RR 7.05). 1

Cerebral Edema from Brain Tumors

• Administer 10 mg IV initially, followed by 4 mg every 6 hours intramuscularly until symptoms subside (typically 12-24 hours). 5
• For palliative management of recurrent or inoperable brain tumors, maintenance therapy of 2 mg two to three times daily may be effective. 5

Perioperative Care

• In bariatric and gastrointestinal surgery, a single 8 mg dose at induction of anesthesia reduces postoperative ileus, pain intensity, and length of stay. 1
• In total joint arthroplasty, perioperative dexamethasone reduces length of stay, postoperative pain, and stress response with only physiological blood glucose elevation as a side effect. 1
• Dexamethasone does not increase postoperative wound infections, systemic infections, or anastomotic leakage. 1

Shock and Emergency Conditions

• For unresponsive shock, dosing ranges from 1-6 mg/kg as a single IV injection to 40 mg initially followed by repeat injections every 2-6 hours while shock persists. 5
• Continue high-dose therapy only until patient stabilization, usually not longer than 48-72 hours, due to peptic ulceration risk. 5

Acute Allergic Disorders

• Day 1: 4-8 mg intramuscularly; Days 2-3: 3 mg daily in divided doses; Day 4: 1.5 mg in divided doses; Days 5-6: 0.75 mg daily; Day 7: no treatment; Day 8: follow-up. 5

Musculoskeletal Injections

• Large joints (knee): 2-4 mg intra-articular 5
• Small joints (interphalangeal): 0.8-1 mg 5
• Bursae: 2-3 mg 5
• Soft tissue infiltration: 2-6 mg 5
• Frequent intra-articular injection may damage joint tissues; frequency typically ranges from once every 3-5 days to once every 2-3 weeks. 5

Relative Potency and Mechanism

• Dexamethasone has 5-6 times greater glucocorticoid potency than prednisone. 6
• It suppresses inflammatory cytokine production at the transcriptional level and directly binds inflammatory markers including IL-1, IL-6, IL-8, IL-12, IL-21, and their receptors. 7
• Superior CNS penetration makes it preferred when central nervous system activity is required. 6

Critical Contraindications and Pitfalls

• Never use dexamethasone for hand, foot, and mouth disease; supportive care with acetaminophen or NSAIDs is appropriate. 8
• Avoid in neonatal meningitis, as evidence is insufficient and treatment groups in trials were poorly balanced. 1
• For chronic ocular conditions, loteprednol is preferred over dexamethasone due to lower intraocular pressure elevation risk. 6
• In patients with advanced glaucoma or history of glaucoma procedures, avoid dexamethasone and use loteprednol instead. 6
• Monitor for hyperglycemia (most common adverse event at 70-76%), new infections (24-25%), and barotrauma (7-10%) in critically ill patients. 3
• Antifungal prophylaxis should be strongly considered in patients receiving steroids for CAR T-cell complications. 1