Dexamethasone


Article Author:
Donavon Johnson


Article Editor:
Brendan Kelley


Editors In Chief:
Rodrigo Kuljis
Oleg Chernyshev
Aninda Acharya


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/18/2019 10:50:14 PM

Indications

Dexamethasone has a wide variety of uses in the medical field. As a treatment, dexamethasone has been useful in the treatment of acute exacerbations of multiple sclerosis, allergies, cerebral edema, inflammation, and shock. Patients with conditions such as asthma, atopic and contact dermatitis, and drug hypersensitivity reactions have benefited from the use of dexamethasone.[1]

In endocrinology, dexamethasone has been found useful as a test for Cushing syndrome.[2] This test begins with a low dose test. There are 2 versions of this test: the standard two-day test and the overnight test. With the standard test, 0.5 mg oral dose of dexamethasone is given every 6 hours for 2 days. Six hours after the final dose is given serum cortisol levels are measured. The overnight test begins with a 1 mg oral dose of dexamethasone at 11:00 pm with a second 1 mg oral dose at midnight. The following morning, serum cortisol levels are tested between 8:00 am and 9:00 am. The test is read as a positive screening test for Cushing syndrome if the final cortisol reading is high, signaling that the more specific confirmative high dose dexamethasone suppression test should be ordered. The high dose dexamethasone suppression test has three forms: the standard 2-day test, the overnight test, and the intravenous (IV) test. With all 3 versions of the test, baseline serum cortisol levels need to be determined before commencing with the test. Baseline serum can be measured with a 24-hour urinary free cortisol test.[3] The standard 2-day test uses 2 mg of oral dexamethasone given every 6 hours for 2 days. During the 2-day exam, urine is collected and tested for free cortisol and 6 hours after the final dose of dexamethasone; blood is drawn to measure the serum cortisol level. The overnight test begins with an 8 mg oral dose of dexamethasone at 11:00 pm. The following morning between 8:00 am, and 9:00 am, serum cortisol is measured. The IV test is the shortest of the test. One milligram of dexamethasone is given via continuous intravenous infusion per hour for 7 hours. Serum cortisol is measured at the end of 7 hours.

Off-label indications are as follows. Dexamethasone is used in the treatment of chemotherapy-induced nausea and vomiting. It is used in the prevention and treatment of altitude sickness. It has also been used in the treatment of spinal cord compression due to metastases in oncological cases.[4]

Mechanism of Action

Dexamethasone is a potent glucocorticoid with very little, if any, mineralocorticoid activity.[5] Dexamethasone’s effect on the body is seen in a variety of ways. It has been shown to work is by suppressing migration of neutrophils and decreasing lymphocyte colony proliferation. It has been shown that capillary membrane becomes less permeable as well. Lysosomal membranes have increased stability. There are higher concentrations of vitamin A compounds in the serum, and prostaglandin and some cytokines (interleukin-1, interleukin-12, interleukin-18, tumor necrosis factor, interferon gamma, and granulocyte-macrophage colony stimulating factor) are inhibited. Increased levels of surfactant and improved pulmonary circulation have also been shown with dexamethasone use. Dexamethasone is metabolized by the liver and excreted in the urine mainly. Dexamethasone has a half-life of approximately 3 hours.

Administration

Dexamethasone is available in various formulations. As a tablet, it is available in strengths ranging from 0.5 mg to 6 mg. Other forms of administration are as an injectable suspension or as an oral solution.[6]

  • In the treatment of inflammation, it is advised to begin with low doses of 0.75 mg/day, which may be titrated to 9 mg/day, with dosing divided into 2 to 4 doses throughout the day. This applies to intravenous, intramuscular, and oral administrations. Less may be used when directly administered to the lesion or tissue with dosing ranging from 0.2 to 6 mg per day.[7]
  • For the treatment of acute multiple sclerosis exacerbations, 30 mg oral daily doses taken for seven days is recommended followed by 1 month of 4 to 12 mg oral daily doses.
  • As cerebral edema may be a life-threatening condition, aggressive treatment is necessary. It is recommended that 10 mg of intravenous dexamethasone be administered followed by 4 mg of intramuscular administration given every 6 hours. In this instance, it is necessary to titrate down over 7 days to discontinue dexamethasone therapy.[8]
  • In the treatment of circulatory shock, it is advised to administer 1 to 6 mg/kg of intravenous dexamethasone as a one-time bolus. This regiment may be substituted for 40 mg given intravenously every 2 to 6 hours as needed. Treatment with high dose dexamethasone is not recommended beyond 2 to 3 days.
  • Allergic reactions have been shown to improve with a 6-day regiment beginning with 4 to 8 mg intramuscular injection on the first day. This is followed by oral doses on days 2 to 6 beginning with 1.5 mg every 12 hours for days 2 and 3, 0.75 mg every 12 hours for the third day, and finally 0.75 mg daily for days 5 and 6. The patient should appropriately be titrated down by day 7 with no dosing necessary on day 7.

Adverse Effects

Although dexamethasone is generally well tolerated, it does have its drawbacks as a medication. Most frequent adverse effect reported by patients is the presence of insomnia after use. Some other frequent adverse effects reported by patients include acne, indigestion, weight gain, increased appetite, anorexia, nausea, vomiting, acne, agitation, and depression. There have been reports of adrenal suppression, arrhythmias, spermatogenic changes, glaucoma, hypokalemia, pulmonary edema, pseudotumor cerebri, and increased intracranial pressure.[9]

Contraindications

Dexamethasone use is contraindicated if patients have systemic fungal infections, hypersensitivity to dexamethasone, or cerebral malaria. It is also contraindicated to administer live or live-attenuated vaccines during the use of dexamethasone as the immune system is being suppressed and will less like form a strong enough immune response placing the patient at risk. It is still okay to administer killed or inactivated vaccines although it should be noted that immune response may be attenuated and it is unpredictable if immunity with developing as a result.[10]

In patients with cirrhosis, diverticulitis, myasthenia gravis, renal insufficiency, or ulcerative diseases such as peptic ulcer disease or ulcerative colitis, it is important to use caution when prescribing dexamethasone. It is also recommended to use dexamethasone with caution during pregnancy as there is an increased risk of oral cleft formations. It has been shown that large doses can increase blood pressure. In patients with recent myocardial infarction, it is advised to proceed with caution as an increase in free wall rupture of the left ventricle has been reported with use of dexamethasone. Suppression of the hypothalamus pituitary adrenal axis (HPA axis) occurs with use, and therefore rapid withdrawal of dexamethasone is not recommended. It is important to gradually increase and/or decrease any corticosteroid due to its effect on the HPA axis.

Latent diseases such as fungal (Candida, Cryptococcus, Pneumocystis), parasitic (Toxoplasmosis, Amebiasis, Strongyloides), and bacterial (Mycobacterium, Nocardia) infections may become active due to suppression of the immune system.[11]

Steroid use may inhibit bone formation and may lead to the formation of osteoporosis. Caution should be taken when prescribing dexamethasone to populations at higher risk for osteoporosis.

Enhancing Healthcare Team Outcomes

Dexamethesone is widely prescribed by many healthcare professionals including the nurse practitioner. However, it is important to know that this potent steroid has many adverse effects and patient monitoring is essential. In general, long term prescription should be avoided and the drug tapered quickly if the patient is improving. If chronic use is warranted, then the patient must be educated about the potential side effects of the steroid. Healthcare workers must monitor the patient for mood changes, development of osteroporosis, weight gain, hyperglycemia, electrolyte changes and depression.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Dexamethasone - Questions

Take a quiz of the questions on this article.

Take Quiz
Select the correct statement about the use of intravenous dexamethasone for acute migraine treatment.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following corticosteroids would exhibit the greatest anti-inflammatory activity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with congestive heart failure is stabilized on lisinopril 25 mg once a day, and furosemide 20 mg once a day, along with a low-sodium, high potassium diet. The patient later requires corticosteroid therapy for an unrelated condition. Which of the following glucocorticoids would be most appropriate for this patient and his condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
There are three zones of the adrenal cortex; zona glomerulosa, zona fasciculata, and zona reticularis. Which of the following drugs is most similar to the hormone released from the zona fasciculata?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Dexamethasone is a potent glucocorticoid with very little if any mineralocorticoid activity. When used in humans, suppression of the hypothalamus pituitary adrenal axis (HPA axis) occurs. Which of the following measures is important to consider when treating with dexamethasone?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Dexamethasone - References

References

Eckhard L,Jones T,Collins JE,Shrestha S,Fitz W, Increased postoperative dexamethasone and gabapentin reduces opioid consumption after total knee arthroplasty. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2019 Mar 2;     [PubMed]
Polderman JAW,Farhang-Razi V,van Dieren S,Kranke P,DeVries JH,Hollmann MW,Preckel B,Hermanides J, Adverse side-effects of dexamethasone in surgical patients - an abridged Cochrane systematic review. Anaesthesia. 2019 Mar 1;     [PubMed]
Kolias AG,Edlmann E,Thelin EP,Bulters D,Holton P,Suttner N,Owusu-Agyemang K,Al-Tamimi YZ,Gatt D,Thomson S,Anderson IA,Richards O,Whitfield P,Gherle M,Caldwell K,Davis-Wilkie C,Tarantino S,Barton G,Marcus HJ,Chari A,Brennan P,Belli A,Bond S,Turner C,Whitehead L,Wilkinson I,Hutchinson PJ, Dexamethasone for adult patients with a symptomatic chronic subdural haematoma (Dex-CSDH) trial: study protocol for a randomised controlled trial. Trials. 2018 Dec 4;     [PubMed]
Corssmit EPM,Dekkers OM, Screening in adrenal tumors. Current opinion in oncology. 2019 Mar 5;     [PubMed]
Bano G,Mir F,Beharry N,Wilson P,Hodgson S,Schey S, A Novel Medical Treatment of Cushing's Due to Ectopic ACTH in a Patient With Neurofibromatosis Type 1. International journal of endocrinology and metabolism. 2013 Winter;     [PubMed]
Monreal JA,Duval F,Mokrani MC,Fattah S,Palao D, Differences in multihormonal responses to the dopamine agonist apomorphine between unipolar and bipolar depressed patients. Journal of psychiatric research. 2019 Feb 19;     [PubMed]
Teachey DT,Pui CH, Comparative features and outcomes between paediatric T-cell and B-cell acute lymphoblastic leukaemia. The Lancet. Oncology. 2019 Mar;     [PubMed]
Brinks J,van Dijk EHC,Habeeb M,Nikolaou A,Tsonaka R,Peters HAB,Sips HCM,van de Merbel AF,de Jong EK,Notenboom RGE,Kielbasa SM,van der Maarel SM,Quax PHA,Meijer OC,Boon CJF, The Effect of Corticosteroids on Human Choroidal Endothelial Cells: A Model to Study Central Serous Chorioretinopathy. Investigative ophthalmology     [PubMed]
Matheson EC,Thomas H,Case M,Blair H,Jackson RK,Masic D,Veal G,Halsey C,Newell DR,Vormoor J,Irving JAE, Glucocorticoids and selumetinib are highly synergistic in RAS pathway mutated childhood acute lymphoblastic leukemia through upregulation of BIM. Haematologica. 2019 Jan 17;     [PubMed]
Orton S,Censani M, Iatrogenic Cushing's Syndrome Due to Intranasal Usage of Ophthalmic Dexamethasone: A Case Report. Pediatrics. 2016 May;     [PubMed]
Sun W,Wang D,Yu C,Huang X,Li X,Sun S, Strong synergism of dexamethasone in combination with fluconazole against resistant Candida albicans mediated by inhibiting drug efflux and reducing virulence. International journal of antimicrobial agents. 2017 Sep;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Neurology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Neurology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Neurology, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Neurology. When it is time for the Neurology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Neurology.