What is the recommended dexamethasone (Decadron) dosage and administration instructions for an adult COVID‑19 patient requiring supplemental oxygen or mechanical ventilation?

Dexamethasone Dosing for COVID-19

For hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation, administer dexamethasone 6 mg once daily (oral or intravenous) for up to 10 days or until hospital discharge, whichever comes first. 1

Patient Selection: Who Should Receive Dexamethasone

Give dexamethasone only to patients requiring respiratory support:

• Patients on invasive mechanical ventilation (mortality reduced from 41.4% to 29.3%, absolute risk reduction 12.1%) 1
• Patients requiring supplemental oxygen without mechanical ventilation (mortality reduced from 26.2% to 23.3%, absolute risk reduction 2.9%) 2, 1
• Do NOT give dexamethasone to patients not requiring oxygen (mortality actually increased from 14.0% to 17.8% in this group, demonstrating harm) 2, 3, 1

Exact Dosing Instructions

Standard regimen:

• Dexamethasone 6 mg once daily 2, 1
• Route: Oral or intravenous (equivalent efficacy) 1
• Duration: Up to 10 days OR until hospital discharge, whichever occurs first 2, 1

Do not extend beyond 10 days: Extended duration (>10 days) is associated with significantly increased mortality (36.5% vs 28.5%, p=0.003) compared to standard 10-day duration 4

Do not continue after discharge: Continuing dexamethasone after hospital discharge provides no benefit in reducing readmissions or mortality (OR 0.87,95% CI 0.58-1.30) 5

Higher Dose Consideration (12 mg)

The 12 mg dose did not demonstrate statistically significant benefit over 6 mg in patients with severe hypoxemia requiring ≥10 L/min oxygen or mechanical ventilation 6

• Median days alive without life support: 22.0 days (12 mg) vs 20.5 days (6 mg), adjusted difference 1.3 days (95% CI 0-2.6, p=0.07) 6
• 28-day mortality: 27.1% (12 mg) vs 32.3% (6 mg), adjusted RR 0.86 (99% CI 0.68-1.08) 6
• Stick with 6 mg as the evidence-based standard dose 2, 1

Timing of Initiation

Start dexamethasone immediately upon oxygen requirement:

• Initiate as soon as SpO2 drops below 92% and supplemental oxygen is started 7, 3
• The RECOVERY trial demonstrated clear benefit when started at the time of oxygen requirement 1
• Do not delay initiation once respiratory support begins 3

Concurrent Therapies

All patients receiving dexamethasone should also receive:

• Prophylactic anticoagulation (low molecular weight heparin preferred) for thromboprophylaxis 3
• Consider IL-6 receptor antagonists (tocilizumab or sarilumab) for patients progressing despite corticosteroids or within first 24 hours of ventilatory support 2

Common Pitfalls to Avoid

Critical errors that worsen outcomes:

• Never give dexamethasone to non-hypoxic patients (SpO2 ≥92% on room air) as this causes harm through immunosuppression without benefit 2, 3, 1
• Never extend beyond 10 days as this significantly increases mortality 4
• Never prescribe at discharge for outpatient continuation as this provides no benefit 5
• Never use doses other than 6 mg daily as higher doses (12 mg) show no additional benefit and lower doses are inadequately studied 6, 1

Monitoring During Treatment

Track these parameters:

• SpO2 target: maintain 90-96%, not higher than 96% to avoid hyperoxia 7
• Blood glucose (dexamethasone causes hyperglycemia) 3
• Signs of secondary infection (bacterial, fungal) given immunosuppression 3
• Respiratory status for deterioration requiring escalation of support 2