Glucocorticoids
ATC code: H02AB02 (Dexamethasone)
Binds intracellular glucocorticoid receptors, translocates to the nucleus, and suppresses transcription of pro-inflammatory genes. Potent anti-inflammatory activity – 25–30 times stronger than hydrocortisone. Virtually no mineralocorticoid activity. Long-acting – half-life 36–54 hours.
First line
First-line for peritumoral cerebral edema and perioperative management in neurosurgery. Loading dose 10 mg IV, then 4 mg every 6 hours. Reduces vascular permeability and vasogenic edema. Not effective for cytotoxic edema – for example, in ischemic stroke.
Adjunct
Component of standard triple antiemetic regimen for chemotherapy. Per ASCO and NCCN guidelines, dexamethasone is given with a 5-HT3 receptor antagonist and an NK1 receptor antagonist. Doses 8–20 mg depending on the emetogenicity of the regimen.
First line
First-line in hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation. The RECOVERY trial (2020, over 6,000 patients) showed a one-third reduction in 28-day mortality in ventilated patients and a one-fifth reduction in those on oxygen. No benefit in patients not requiring oxygen. Dose: 6 mg/day for 10 days.
FDA category C. Crosses the placenta (unlike prednisolone, which is metabolized by the placenta). High doses in the first trimester are associated with a small increased risk of cleft palate. Used for strict indications – for example, fetal lung maturation in threatened preterm labor.
dexamethasone is evaluated for the following indications with varying evidence strength: Cerebral edema (evidence tier A), COVID-19 (evidence tier A), Chemotherapy-induced nausea and vomiting prophylaxis (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of dexamethasone (≥ 1 in 100): Hyperglycemia, Increased appetite, Insomnia, Mood changes – irritability, euphoria, Dyspepsia. See the Safety section for uncommon and serious reactions.
FDA category C. FDA category C. Crosses the placenta (unlike prednisolone, which is metabolized by the placenta). High doses in the first trimester are associated with a small increased risk of cleft palate. Used for strict indications – for example, fetal lung maturation in threatened preterm labor.
dexamethasone is contraindicated in: Systemic fungal infections (unless patient is on antifungal therapy); Hypersensitivity to dexamethasone; Live vaccines at immunosuppressive doses. Full list in the Safety section.