Dexamethasone parenteral
- Drugs List
- Therapeutic Indications
- Dosage
- Administration
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Injections of dexamethasone.
Drugs List
Therapeutic Indications
Uses
Adrenal insufficiency - cortical
Cerebral oedema
Cerebral oedema secondary to cerebral tumour
Chemotherapy induced nausea and vomiting
Coronavirus disease 2019 (COVID-19) - treatment
Inflammatory or allergic conditions
Shock - severe (adjunct)
Unlicensed Uses
Bacterial meningitis
Dosage
Individualise the dosage on the basis of the disease and the response of the patient. To minimise the risk of any side effects always use the lowest possible dosage adequate to control the disease process.
In acute, life-threatening situations, administration of dosages exceeding the usual level may be justified. In these circumstances the slower rate of absorption by the intramuscular route should be noted.
During prolonged therapy any inter-current illness, trauma or surgical procedure will require a temporary increase in dosage. If corticosteroids have been stopped following prolonged therapy they may need to be temporarily re-introduced.
Adults
Usual initial dosage is in the range of 400micrograms to 16.6mg a day. Adjust both the dosage and the frequency interval slowly to achieve the lowest dosage, which will maintain an adequate clinical response.
Treatment of haemorrhagic, traumatic or surgical shock
1.7 to 5mg/kg body weight as a single intravenous injection given over several minutes. This may be repeated in 2 to 6 hours if shock persists.
The initial bolus injection may be followed by 1.7 to 5mg/kg bodyweight per 24 hours given by an intravenous infusion (manufacturers recommend different dosages).
Administration of these high dosages should be continued only until the time that the patient's condition has stabilised and usually not longer than 48 to 72 hours.
Cerebral oedema associated to cerebral tumour
Initially 8.3mg intravenously, followed by 3.3mg intramuscularly every 6 hours until symptoms of cerebral oedema subside.
Response is usually noted within the first 24 hours and the dosage may be reduced after two to four days. Gradually discontinue the dosage over five to seven days. Patients with recurrent or inoperable tumours, maintenance therapy may be effective at doses of 1.7mg intramuscularly or intravenously two to three times daily.
Cerebral oedema
Initial dose: 8mg to 16mg intravenously.
Maintenance dose: 5mg intravenously or intramuscularly every 6 hours until a satisfactory result has been obtained. These doses may be needed for several days post operation.
Some manufacturers suggest the following high dosages of dexamethasone for initiating treatment in life-threatening cerebral oedema (see suggested doses below). After the first day of high dose administration the dose is scaled down over an eight day period of intensive therapy. Wherever possible convert the patient to oral dexamethasone as soon as possible.
High dose schedule in life threatening cerebral oedema
Initial dose: 41.5mg intravenously.
First to third day: 6.6mg intravenously every 2 hours.
Fourth day: 3.3mg intravenously every 2 hours.
Fifth to eighth day: 3.3mg intravenously every 4 hours.
Thereafter decrease daily dose by 3.3mg.
Intrasynovial, Intralesional, and Soft Tissue Injection
Dosage varies with degree of inflammation and the size and location of the affected area.
Treatment may be once every three to five days (e.g. for bursae) to once every two to three weeks (for joints), depending upon the response. Dosage recommendations are:
Large joint (e.g. knee): 1.6mg to 3.3mg.
Small joint (e.g. interphalangeal, temporomandibular): 0.6mg to 0.8mg.
Bursae: 1.6mg to 3mg.
Tendon Sheaths (inject into tendon sheath, not directly into tendon): 0.3mg to 0.8mg.
Soft Tissue Infiltration: 1.7mg to 5mg.
Ganglia: 0.8mg to 1.7mg.
Ulcerative Colitis
4mg diluted in 120ml saline as a rectal drip instillation.
Adjunctive Treatment of Bacterial Meningitis (unlicensed)
10mg every 6 hours for four days by intravenous injection.
Coronavirus disease 2019 (COVID-19)
6mg once daily for up to 10 days by intravenous injection.
Elderly
The treatment of elderly patients particularly if long term, needs to be planned bearing in mind the more serious consequences of the common side effects of corticosteroids in old age, especially osteoporosis, diabetes, hypokalaemia, hypertension, susceptibility to infection and thinning of skin. Close clinical supervision is necessary to avoid life threatening reactions.
Children
Dosage requirements are variable. Usually 167 micrograms to 400 micrograms/kg body weight daily.
To lessen retardation of growth and minimise suppression of the hypothalamic-pituitary-adrenal axis, dosage should be limited to a single dose on alternate days, where possible.
High dose schedule in life threatening cerebral oedema
Children 35kg and over
Initial dose: 20.8mg intravenously.
First to third day: 3.3mg intravenously every 2 hours.
Fourth day: 3.3mg intravenously every 4 hours.
Fifth to eighth day: 3.3mg intravenously every 6 hours.
Thereafter, decrease daily dose by 1.7mg.
Children under 35kg
Initial dose: 16.6mg intravenously.
First to third day: 3.3mg intravenously every 3 hours.
Fourth day: 3.3mg intravenously every 6 hours.
Fifth to eighth day: 1.7mg intravenously every 6 hours.
Thereafter decrease daily dose by 0.83mg.
Adjunctive Treatment in Bacterial Meningitis (unlicensed)
Children aged 3 months to 16 years
150 micrograms/kg every 6 hours for four days starting before or with the first dose of antibacterial.
Maximum dose: 10mg
Children aged 16 to 18 years
10mg every 6 hours for four days.
Coronavirus disease 2019
Children aged 12 to 18 years old weighing at least 40kg
6mg once daily for up to 10 days by intravenous injection.
The following dosage schedule may also be suitable:
Inflammatory or Allergic Disorders
Children aged 12 years to 18 years
Initial dose: 400 micrograms to 20mg daily by intravenous injection, intravenous infusion or intramuscular injection.
Children aged 1 month to 12 years
Maintenance dose: 83 to 333 microgram/kg, given in 1 or 2 divided doses daily.
Maximum dose: 20mg daily.
Adrenal Insufficiency
250 to 500 micrograms/squared metre 12 hourly as required.
Coronavirus disease 2019
Children aged 1 month to 18 years (unlicensed)
150 micrograms/kg once daily for 10 days. Maximum 6mg once daily.
Additional Dosage Information
Dexamethasone withdrawal
Adrenal cortical atrophy develops during prolonged therapy and may persist for many years after stopping treatment.
Too rapid a reduction of corticosteroid dosage following prolonged therapy can lead to acute adrenal insufficiency, hypotension and death. However, this is more applicable to corticosteroids with an indication where continuous therapy is given.
Patients receiving doses greater than approximately 1mg of dexamethasone daily (approximately normal physiological levels) for more than 3 weeks should be withdrawn gradually. Reduction method will depend on the likelihood of disease relapse during dose reduction. Clinical assessment of disease activity may be required during withdrawal. If relapse is unlikely but there is uncertainty about HPA suppression, the dose may be reduced rapidly to 1mg dexamethasone and then reduced more slowly to allow HPA-axis recovery.
If relapse is unlikely and up to 6mg dexamethasone has been given for less than 3 weeks then abrupt withdrawal is unlikely to result in clinically relevant HPA-axis suppression in the majority of patients.
Even after less than 3 weeks treatment, gradual withdrawal should be considered in the following patient groups:
Patients who have had repeated systemic steroid courses especially if courses were for longer than 3 weeks.
When a short course has been prescribed within one year of stopping a course that had lasted for months or years.
Patients at risk of adrenocortical insufficiency other than exogenous corticosteroid therapy.
Patients receiving doses greater than 6mg daily of dexamethasone.
Patients repeatedly taking doses in the evenings.
Administration
Administration may be by the intravenous, subcutaneous, intramuscular, intra-articular or soft tissue injection or by rectal drip.
Intravenous administration enables high plasma levels to be obtained rapidly. The injection should be given slowly over a period of several minutes.
Contraindications
Administration site infection
Uncontrolled systemic infection
Precautions and Warnings
Children under 18 years
Elderly
Family history of diabetes mellitus
Family history of glaucoma
Breastfeeding
Congestive cardiac failure
Diabetes mellitus
Diverticulitis
Epileptic disorder
Gastrointestinal anastomosis
Glaucoma
Hepatic impairment
History of severe affective disorders
History of steroid myopathy
History of steroid-induced psychosis
History of tuberculosis
Hypertension
Hypothyroidism
Migraine
Myasthenia gravis
Ocular herpes simplex infection
Osteoporosis
Peptic ulcer
Pre-eclampsia
Pregnancy
Recent myocardial infarction
Renal impairment
Severe affective disorders
Thromboembolic disorder
Ulcerative colitis
Administration of live vaccines is not recommended
Consider increased dose during intercurrent illness/trauma/surgery
Consider reintroducing steroids temporarily during illness/trauma/surgery
Disease reactivation may occur in patients with latent TB
Exposure to measles may require prophylaxis with normal immunoglobulin
May activate latent amoebiasis
May mask symptoms or signs of infections
Not all available brands are licensed for all indications
Not all available brands are licensed for all routes of administration
Some formulations contain propylene glycol
Some preps may contain sulfite; caution hypersensit. in asthma/allergy pts
Frequent review needed to titrate dose to disease activity
If visual disturbances occur, perform ophthalmic evaluation
Monitor patients at risk of tumour lysis syndrome
Monitor regularly the height of children receiving prolonged treatment
Pregnancy: Monitor closely patients with pre-eclampsia or fluid retention
Prolonged or high dose may lead to adrenal suppression
Psychological changes may occur during initiation & withdrawal of treatment
Supervise patient closely during drug withdrawal
Adrenal cortical atrophy may persist for years after stopping drug
Antibody response to vaccines may be reduced
Consider septic arthritis post joint inj if pain,fever,swelling occur
Corticosteroids may cause growth retardation in children under 18 years
Oversuppression of immune system may increase susceptibility to infection
Patient should report worrying psychological changes esp. suicidal thoughts
Sudden withdrawal may be inadvisable -see product information/SPC
Advise patient not to take St John's wort concurrently
Advise patients to avoid aspirin and NSAID use
Advise patient to rest treated joint after intra-articular injection
Advise patient to seek urgent medical attention if exposed to measles
Advise those on systemic corticosteroids to avoid chickenpox/H zoster
Consider issuing Steroid Treatment/Steroid Emergency Card
If exposed to chickenpox or Herpes zoster seek urgent medical attention
Divided dosage regimes and evening administration have been associated with an increased suppression of the hypothalamic-pituitary-adrenal axis.
Dexamethasone may exacerbate systemic fungal infections and should not be used unless they are needed to control drug reactions to amphotericin.
Patients (or parents of children) without a definite history of chicken pox should be advised to avoid close personal contact with chicken pox or herpes zoster and seek urgent medical attention if exposed as chicken pox can prove fatal in immunocompromised patients. If exposed while on dexamethasone or within three months of previous use, passive immunisation with varicella/zoster immunoglobulin (VZIG) should be administered within 10 days of the exposure. If chicken pox occurs, treat urgently under specialist care. Do not stop dexamethasone therapy, an upward dosage adjustment may be required.
Some formulations of dexamethasone 3.3 mg/ml injection contain a significant amount of propylene glycol. Neonates, children under 5 years and patients with renal or hepatic impairment should use these products with caution. Serious adverse reactions may occur if the propylene glycol safety threshold is exceeded, particularly in neonates and infants. Monitoring for propylene glycol toxicity is recommended.
Pregnancy and Lactation
Pregnancy
Use dexamethasone with caution during pregnancy.
The manufacturer advises dexamethasone is used only if the benefits to the mother outweigh the potential risk to the foetus. However, if corticosteroids are considered essential, patients with normal pregnancies may be treated as though they were in the non-gravid state. The lowest effective dose required to maintain adequate disease control should be used.
Animal studies have shown teratogenic effects. Human data is limited and as such a potential risk cannot be ruled out. Dexamethasone readily crosses the placenta, foetal serum concentrations are similar to maternal concentrations.
Administration for prolonged periods or repeatedly during pregnancy may increase the risk of intra-uterine growth retardation. Hypoadrenalism may occur in the neonate following prenatal exposure to corticosteroids. However this will usually resolve following birth and is rarely clinically significant.
Lactation
Use dexamethasone with caution during breastfeeding.
The manufacturer states that corticosteroids are excreted into breast milk and may interfere with endogenous corticosteroid production and cause other undesirable effects. Infants of mothers receiving prolonged high dose corticosteroid therapy may experience a degree of adrenal suppression.
Side Effects
Abdominal distension
Acne
Acute pancreatitis
Aggravation of schizophrenia
Allergic dermatitis
Amenorrhoea
Amnesia
Anaphylaxis
Anxiety
Aseptic necrosis
Avascular osteonecrosis
Behavioural disturbances
Bronchospasm
Bruising
Candidiasis
Charcot-like arthropathy
Chorioretinopathy
Cognitive impairment
Confusion
Convulsions
Corneal thinning
Cushingoid changes
Delusions
Depression
Dyspepsia
Ecchymosis
Emotional lability
Euphoria
Exacerbation of epilepsy
Exacerbation of ophthalmic fungal disease
Exacerbation of ophthalmic viral disease
Exophthalmos
Fluid retention
Glaucoma
Hallucinations
Headache
Hirsutism
Hyperpigmentation
Hypersensitivity reactions
Hypertension
Hypokalaemia
Hypokalaemic alkalosis
Hypopigmentation
Impaired carbohydrate tolerance, increased need for anti-diabetic therapy
Impairments of sperm parameters
Increased appetite
Increased intra-ocular pressure
Increased susceptibility to infection
Increased sweating
Injection site reactions
Irregular menstruation
Irritability
Joint destruction
Leucocytosis
Mania
Muscle weakness
Myocardial rupture
Negative calcium balance
Negative nitrogen balance
Negative protein balance
Opportunistic infections
Osteoporosis
Papilloedema
Peptic ulceration with perforation and haemorrhage
Petechiae
Post-injection flare
Posterior subcapsular cataracts
Premature closure of epiphyses
Proximal myopathy
Psychiatric disorders
Psychological dependence
Raised intracranial pressure
Recurrence of dormant tuberculosis
Reduced muscle mass
Scleral thinning
Sleep disturbances
Sodium/water retention
Striae
Suicidal tendencies
Suppression of growth in children and adolescents
Suppression of reactions to skin tests
Suppression of the hypothalamic-pituitary-adrenal axis
Telangiectasia
Tendon rupture
Thinning of skin
Thromboembolism
Ulcerative oesophagitis
Urticaria
Vertebral and long bone fractures
Vertigo
Weight gain
Wound healing retarded
Effects on Laboratory Tests
False negative results may occur with the nitroblue tetrazolium test for bacterial infection.
Withdrawal Symptoms and Signs
Too rapid a reduction of corticosteroid dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and death. A 'withdrawal syndrome' may also occur including fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.
Overdosage
It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.
The following number will direct the caller to the relevant local centre (0844) 892 0111
Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Further Information
Last Full Review Date: December 2019
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.
Summary of Product Characteristics: Dexamethasone 3.8 mg/ml solution for injection. Aspen Pharma Trading Ltd. Revised November 2018.
Summary of Product Characteristics: Dexamethasone 3.3 mg/ml solution for injection. Hameln Pharmaceuticals Ltd. Revised February 2021.
Summary of Product Characteristics: Dexamethasone 3.3 mg/ml solution for injection (vial). Hospira UK Ltd. Revised July 2019.
Summary of Product Characteristics: Dexamethasone 3.3 mg/ml solution for injection (ampoule). Hospira UK Ltd. Revised January 2019.
Summary of Product Characteristics: Dexamethasone 3.3 mg/ml solution for injection or infusion. Wockhardt UK Ltd. Revised March 2017.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 27 October 2022
US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Dexamethasone. Last revised: 31 October 2018
Last accessed: 07 November 2019
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