dexamethasone

REMS

Used systemically and locally in a wide variety of chronic diseases, including:
- Inflammatory,
- Allergic,
- Hematologic,
- Endocrine,
- Neoplastic,
- Dermatologic,
- Autoimmune disorders,
- Cerebral edema,
- Diagnostic agent in adrenal disorders.

Hemady

Multiple myeloma (in combination with other anti-myeloma agents).

Unlabeled Use:

Short-term administration to high-risk mothers before delivery to prevent respiratory distress syndrome in the newborn.
Adjunctive management of nausea and vomiting from chemotherapy.
Airway edema prior to extubation.
To facilitate ventilator weaning in neonates with bronchopulmonary dysplasia.

Action ⬆ ⬇

In pharmacologic doses, suppresses inflammation and the normal immune response.
Suppresses adrenal function at chronic doses of 0.75 mg/day.
Has negligible mineralocorticoid activity.

Therapeutic effects:

Suppression of inflammation and modification of the normal immune response.

Pharmacokinetics ⬆ ⬇

Absorption: Well absorbed after oral administration. Sodium phosphate salt is rapidly absorbed after IM administration. Absorption from local sites (intra-articular, intralesional) is slow but complete.

Distribution: Widely distributed to tissues.

Metabolism/Excretion: Mostly metabolized by the liver.

Half-Life: Low birth weight infants with bronchopulmonary dysplasia: 9.3 hr; Children 3 mo–16 yr: 4.3 hr; Adults: 3–4.5 hr (plasma), 36–54 hr (tissue); adrenal suppression lasts 2.75 days.

Time/Action Profile ⬆ ⬇

(anti-inflammatory activity)

ROUTE	ONSET	PEAK	DURATION
PO	unknown	1–2 hr	72 hr
IM, IV (phosphate)	rapid	unknown	72 hr

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Active untreated infections (may be used in patients being treated for tuberculous meningitis);
Known alcohol or bisulfite hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients);
Epidural use (may result in serious neurological injury or death);
Lactation: Lactation.

Use Cautiously in:

Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time);
Stress (surgery, infections—supplemental doses may be needed);
Potential infections (may mask signs);
OB: Safety not established in pregnancy;
Pedi: Early postnatal administration of high doses can cause significant and persistent reductions in neuromotor and cognitive functioning; results in growth; use lowest possible dose for shortest period of time.

Adv. Reactions/Side Effects ⬆ ⬇

Adverse reactions/side effects are much more common with high-dose/long-term therapy

CV: hypertension, edema

Derm: ↓wound healing, acne, ecchymoses, hirsutism, petechiae

EENT: ↑intraocular pressure, blurred vision, cataracts

Endo: adrenal suppression, hyperglycemia

F and E: hypokalemia, metabolic alkalosis

GI: anorexia, nausea, PEPTIC ULCERATION, vomiting

GU: amenorrhea

Hemat: THROMBOEMBOLISM, thrombophlebitis

Metab: ↑appetite, weight gain

MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain

Neuro: depression, euphoria, ↑intracranial pressure (children only), psychoses, hallucinations, headache, insomnia, personality changes, restlessness

Misc: cushingoid appearance (moon face, buffalo hump), INFECTION, KAPOSI'S SARCOMA

Interactions ⬆ ⬇

Drug-drug:

CYP3A4 inhibitors, including clarithromycin, cobicistat, erythromycin, itraconazole, ketoconazole, and ritonavir, may ↑ levels and risk of toxicity.
CYP3A4 inducers, including carbamazepine, phenobarbital, phenytoin, and rifampin, may ↓ levels and effectiveness.
↑risk of hypokalemia with thiazide and loop diuretics, amphotericin B, or piperacillin/tazobactam.
Hypokalemia may ↑ risk of digoxin toxicity.
May ↑ requirement for insulin or oral hypoglycemic agents.
May ↓ levels of phenytoin and isoniazid.
Oral contraceptives may ↑ levels and risk of toxicity.
↑risk of adverse GI effects with NSAIDs (including aspirin), alcohol, and caffeine.
At chronic doses that suppress adrenal function, may ↓ the antibody response to and ↑ risk of adverse reactions from live-virus vaccines.
May ↑ or ↓ the effects of warfarin.
May ↑ risk of tendon rupture when used with fluoroquinolones.

Route/Dosage ⬆ ⬇

PO IM IV (Adults ): Anti-inflammatory: 0.75–9 mg daily in divided doses every 6–12 hr. Airway edema or extubation: 0.5–2 mg/kg/day divided every 6 hr; begin 24 hr prior to extubation and continue for 24 hr postextubation. Cerebral edema: 10 mg IV; then 4 mg IM or IV every 6 hr until maximal response achieved; then switch to PO regimen and taper over 5–7 days.
PO IM IV (Children ): Airway edema or extubation: 0.5–2 mg/kg/day divided every 6 hr; begin 24 hr prior to extubation and continue for 24 hr postextubation. Anti-inflammatory: 0.08–0.3 mg/kg/day or 2.5–10 mg/m²/day divided every 6–12 hr. Physiologic replacement: 0.03–0.15 mg/kg/day or 0.6–0.75 mg/m²/day divided every 6–12 hr.
PO (Adults ): Suppression test: 1 mg at 11pm or 0.5 mg every 6 hr for 48 hr. Multiple myeloma: 20–40 mg once daily on specific days (based on protocol being used).
IV (Children ): Chemotherapy-induced emesis: 5–20 mg given 15–30 min before treatment. Cerebral edema: Loading dose 1–2 mg/kg followed by 1–1.5 mg/kg/day, divided every 4–6 hr for 5 days (not to exceed 16 mg/day); then taper over 1–6 wk. Bacterial meningitis: 0.6 mg/kg/day divided every 6 hr × 4 days (start at time of first antibiotic dose).
IV PO (Adults ): Chemotherapy-induced emesis: 10–20 mg given 15–30 min before each treatment or 10 mg every 12 hr on each treatment day. Delayed nausea/vomiting: 4–10 mg PO 1–2 times/day for 2–4 days or 8 mg PO every 12 hr for 2 days, then 4 mg PO every 12 hr for 2 days or 20 mg PO 1 hr before chemotherapy, then 10 mg PO every 12 hr after chemotherapy, then 8 mg PO every 12 hr for 2 days, then 4 mg PO every 12 hr for 2 days.
(Adults ): 0.4–6 mg/day.

Availability ⬆ ⬇

(Generic available)

Tablets: 0.5 mg; 0.75 mg; 1 mg; 1.5 mg; 2 mg; 4 mg; 6 mg; 20 mg
Elixirraspberry flavor: 0.5 mg/5 mL
Oral solutioncherry flavor: 0.5 mg/5 mL; 1 mg/mL
Solution for injection (sodium phosphate): 4 mg/mL; 10 mg/mL

Assessment ⬆ ⬇

Indicated for many conditions. Assess involved systems before and periodically during therapy.
Monitor for signs and symptoms of adrenal insufficiency (fatigue, weakness, nausea and vomiting, low BP); dexamethasone should be tapered more slowly.
Monitor for signs and symptoms of hypercorticism (moon face, buffalo hump, stretch marks, obesity, bruising, hyperglycemia, elevated BP) every 6 mo; pediatric patients under one yr of age may require more frequent monitoring (every 3–4 mo); temporary discontinuation, dose reduction, or slowed taper may be needed.
Assess for signs of infection (fever, chills, sore throat, wound that will not heal).
Assess for signs and symptoms of Kaposi's sarcoma (purple, red, or brown skin blotches on skin or inside the mouth) with long-term use.
Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional should these occur.
Pedi: Evaluate growth of children periodically during therapy. Monitor linear growth and weight gain. Adjust doses accordingly.
Cerebral Edema: Assess for changes in level of consciousness and headache during therapy.

Lab Test Considerations:

Verify negative pregnancy test before starting therapy with Hemady.Monitor CBC, electrolytes, serum and urine glucose, and lipid panel routinely during therapy. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia, hypocalcemia, hypernatremia. May ↓ WBC counts. May ↑ serum cholesterol and lipid values.
- May suppress reactions to allergy skin tests.
- Guaiac test stools. Promptly report presence of guaiac-positive stools.
- May ↓ uptake of thyroid ¹²³I or ¹³¹I.
- Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal axis suppression in systemic and chronic topical therapy.
- Dexamethasone Suppression Test: To diagnose Cushing's syndrome, obtain baseline cortisol level; administer dexamethasone at 11 pm and obtain cortisol levels at 8 am the next day. Normal response is a decreased cortisol level.
- Alternative method: Obtain baseline 24-hr urine for 17-hydroxycorticosteroid (OHCS) concentrations; then begin 48-hr administration of dexamethasone. Second 24-hr urine for 17-OHCS is obtained after 24 hr of dexamethasone.

Implementation ⬆ ⬇

Rate: Administer infusions over 15–30 min.

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Y-Site Incompatibility:

Do not confuse dexamethasone with dexmedetomidine.
If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol.
Periods of stress, such as surgery, may require supplemental systemic corticosteroids.
PO: Administer with meals to minimize GI irritation; do not administer with grapefruit juice.
- For patients with difficulty swallowing, tablets may be crushed and administered with fluids or soft foods like applesauce, pudding, or chocolate syrup.
- Use calibrated measuring device to ensure accurate dose of liquid forms.
IM: IM doses should not be administered when rapid effect is desirable. Do not dilute with other solution or admix.
Diluent: May be given undiluted.Concentration: 4–10 mg/mL.
Rate: Administer over 1–4 min if dose is <10 mg.
Intermittent Infusion: Diluent: High-dose therapy should be added to D5W or 0.9% NaCl solution. Solution should be clear and colorless to light yellow; use diluted solution within 24 hr.Concentration: Up to 10 mg/mL.

IV Administration:

Patient/Family Teaching ⬆ ⬇

Educate patient on reason for dexamethasoneand side effects. Instruct them to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Do not share medication with others, even if they have similar symptoms; may be harmful. Advise patient to read Patient Information before starting and with each Rx refill in case of changes.
- Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed.
- Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening. Medical ID should be worn in case of emergencies.
- Advise patient to avoid grapefruit juice during therapy.
- Advise patient to notify health care professional of signs and symptoms of hypercorticism (acne; thicker or more hair on body and face; bruising easily; fatty pad or hump between shoulders [buffalo hump]; rounding of face [moon face]; pink or purple stretch marks on skin of abdomen, thighs, breasts, and arms; ankle swelling), adrenal suppression (tiredness, weakness, nausea and vomiting, low blood pressure), worsening of allergies (eczema, rhinitis), or infection (fever, chills, pain, feeling tired, aches, nausea and vomiting).
- May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
- Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur.
- Corticosteroids cause immunosuppression and may mask symptoms of infection. May worsen existing tuberculosis; fungal, bacterial, viral, or parasitic infections; or ocular herpes simplex. Notify health care professional immediately if exposed to chicken pox or measles.
- Caution patient to avoid vaccinations without first consulting health care professional.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other medications, especially St. John's wort.
- Advise parents that use may cause shortened stature.
- Hemady may cause fetal harm. Advise females of reproductive potential to use effective contraception during therapy and for 1 mo after last dose and to avoid breastfeeding during therapy and for 2 wk after last dose. Instruct patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Hypoadrenalism may occur in infants born to mothers receiving corticosteroids during pregnancy. Observe infant for signs of hypoadrenalism (poor feeding, irritability, weakness, vomiting).

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇