dexamethasone

(dex a meth' a sone)

dexamethasone
Oral, topical dermatologic aerosol and gel, ophthalmic suspension:

Aeroseb-Dex, Decadron, Dexameth, Dexasone (CAN), Dexone, Hexadrol, Maxidex Ophthalmic

dexamethasone acetate
IM, intra-articular, or soft-tissue injection:

Cortastat LA, Dalalone L.A., Decaject LA, Dexasone-L.A., Dexone LA, Solurex LA

dexamethasone sodium phosphate
IV, IM, intra-articular, intralesional injection; respiratory inhalant; intranasal steroid; ophthalmic solution and ointment; topical dermatologic cream:

Cortastat, Dalalone, Decadron Phosphate, Decadron Phosphate Ophthalmic, Decadron Phosphate Turbinaire, Decaject, Dexasone, Dexone, Hexadrol Phosphate, Solurex Pregnancy Category C
Drug classes

Corticosteroid Glucocorticoid Hormone
Therapeutic actions

Enters target cells and binds to specific receptors, initiating many complex reactions that are responsible for its antiinflammatory and immunosuppressive effects.
Indications

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Hypercalcemia associated with cancer Short-term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (SLE), dermatologic diseases (pemphigus), status asthmaticus, and autoimmune disorders Hematologic disorders: Thrombocytopenic purpura, erythroblastopenia Trichinosis with neurologic or myocardial involvement Ulcerative colitis, acute exacerbations of multiple sclerosis, and palliation in some leukemias and lymphomas Cerebral edema associated with brain tumor, craniotomy, or head injury Testing adrenocortical hyperfunction Unlabeled uses: Antiemetic for cisplatin-induced vomiting, diagnosis of depression

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Intra-articular or soft-tissue administration: Arthritis, psoriatic plaques Respiratory inhalant: Control of bronchial asthma requiring corticosteroids in conjunction with other therapy Intranasal: Relief of symptoms of seasonal or perennial rhinitis that responds poorly to other treatments Dermatologic preparations: Relief of inflammatory and pruritic manifestations of dermatoses that are steroid-responsive Ophthalmic preparations: Inflammation of the lid, conjunctiva, cornea, and globe Contraindicated with infections, especially tuberculosis, fungal infections, amebiasis, vaccinia and varicella, and antibiotic-resistant infections, allergy to any component of the preparation used. Use cautiously with renal or hepatic disease; hypothyroidism, ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation.

Contraindications and cautions

Available forms

Tablets—0.25, 0.5, 0.75, 1, 1.5, 2, 4, 6 mg; elixir—0.5 mg/5 mL; oral solution—0.5 mg/5 mL; injection—8 mg/mL, 16 mg/mL, 4 mg/mL, 10 mg/mL, 20 mg/mL, 24 mg/mL; aerosol—84 mcg/actuation; ophthalmic solution—0.1%; ophthalmic suspension—0.1%; ophthalmic ointment—0.05%; topical ointment—0.05%; topical cream—0.05%, 0.1%; topical aerosol—0.01%, 0.04%
Dosages ADULTS Systemic administration

Individualize dosage based on severity of condition and response. Give daily dose before 9 AM to minimize adrenal suppression. If long-term therapy is needed, alternate-day therapy with a short-acting steroid should be considered. After long-term therapy, withdraw drug slowly to avoid adrenal insufficiency. For maintenance therapy, reduce initial dose in small increments at intervals until the lowest clinically satisfactory dose is reached.
Oral (dexamethasone, oral)

0.75–9 mg/day. • Suppression tests for Cushing's syndrome: 1 mg at 11 PM; assay plasma cortisol at 8 PM the next day. For greater accuracy, give 0.5 mg q 6 hr for 48 hr, and collect 24-hr urine to determine 17-OH-corticosteroid excretion. • Suppression test to distinguish Cushing's syndrome due to ACTH excess from that resulting from other causes: 2 mg q 6 hr for 48 hr. Collect 24-hr urine to determine 17-OH-corticosteroid excretion.
IM (dexamethasone acetate)

8–16 mg; may repeat in 1–3 wk. Dexamethasone phosphate: 0.5–0.9 mg/day; usual dose range is one-third to one-half the oral dose.
IV (dexamethasone sodium phosphate)

0.5–9 mg/day. • Cerebral edema: 10 mg IV and then 4 mg IM q 6 hr; change to oral therapy, 1– 3 mg tid, as soon as possible and taper over 5–7 days.
PEDIATRIC PATIENTS IV

Individualize dosage based on severity of condition and response, rather than by strict adherence to formulas that correct adult doses for age or body weight. Carefully observe growth and development in infants and children on long-term therapy. • Unresponsive shock: 1–6 mg/kg as a single IV injection (as much as 40 mg initially followed by repeated injections q 2–6 hr has been reported).
Intralesional (dexamethasone acetate) ADULTS AND PEDIATRIC PATIENTS

4–16 mg intra-articular, soft tissue; 0.8–1.6 mg intralesional.
(dexamethasone sodium phosphate)

0.4–6 mg (depending on joint or soft-tissue injection site).
Respiratory inhalant (dexamethasone sodium phosphate) 84 mcg released with each actuation. ADULTS

3 inhalations tid–qid, not to exceed 12 inhalations/day.
PEDIATRIC PATIENTS

2 inhalations tid–qid, not to exceed 8 inhalations/day.
Intranasal (dexamethasone sodium phosphate)

Each spray delivers 84 mcg dexamethasone.
ADULTS

2 sprays (168 mcg) into each nostril bid–tid, not to exceed 12 sprays (1,008 mcg)/day.
PEDIATRIC PATIENTS

1 or 2 sprays (84–168 mcg) into each nostril bid, depending on age, not to exceed 8 sprays (672 mcg). Arrange to reduce dose and discontinue therapy as soon as possible.
Topical dermatologic preparations

Apply sparingly to affected area bid–qid.
Ophthalmic solutions, suspensions

Instill 1 or 2 drops into the conjunctival sac q 1 hr during the day and q 2 hr during the night; after a favorable response, reduce dose to 1 drop q 4 hr and then 1 drop tid–qid.
Ophthalmic ointment

Apply a thin coating in the lower conjunctival sac tid–qid; reduce dosage to bid and then qid after improvement.
Pharmacokinetics
Route Oral IM IV Onset Slow Rapid Rapid Peak 1–2 hr 30–60 min 30–60 min Duration 2–3 days 2–3 days 2–3 days

Metabolism: Hepatic; T1/2: 110–210 min Distribution: Crosses placenta; enters breast milk Excretion: Urine
IV facts

Preparation: No preparation required. Infusion: Administer by slow, direct IV injection over 1 min. Incompatibilities: Do not combine with daunorubicin, doxorubicin, metaraminol, vancomycin.
Adverse effects

Adverse effects depend on dose, route, and duration of therapy. The first list is primarily associated with absorption; the list following is related to specific routes of administration.
Systemic administration

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CNS: Seizures, vertigo, headaches, pseudotumor cerebri, euphoria, insomnia, mood swings, depression, psychosis, intracerebral hemorrhage, reversible cerebral atrophy in infants, cataracts, increased IOP, glaucoma CV: Hypertension, CHF, necrotizing angiitis Endocrine: Growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state, secondary adrenocortical and pituitary unresponsiveness GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention GU: Amenorrhea, irregular menses Hematologic: Fluid and electrolyte disturbances, negative nitrogen balance, increased blood sugar, glycosuria, increased serum cholesterol, decreased serum T3 and T4 levels Hypersensitivity: Anaphylactoid or hypersensitivity reactions Musculoskeletal: Muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous fractures Other: Impaired wound healing; petechiae; ecchymoses; increased sweating; thin and fragile skin; acne; immunosuppression and masking of signs of infection; activation of latent infections, including TB, fungal, and viral eye infections; pneumonia; abscess; septic infection; GI and GU infections Musculoskeletal: Osteonecrosis, tendon rupture, infection CNS: Blindness (when used on face and head—rare) Endocrine: Suppression of HPA function due to systemic absorption Respiratory: Oral, laryngeal, pharyngeal irritation Other: Fungal infections CNS: Headache Dermatologic: Urticaria Endocrine: Suppression of HPA function due to systemic absorption GI: Nausea Respiratory: Nasal irritation, fungal infections, epistaxis, rebound congestion, perforation of the nasal septum, anosmia

Intra-articular

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Intralesional therapy Respiratory inhalant

Intranasal

Topical dermatologic ointments, creams, sprays

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Endocrine: Suppression of HPA function due to systemic absorption, growth retardation in children (children may be at special risk for systemic absorption because of their large skin surface area to body weight ratio) Local: Local burning, irritation, acneiform lesions, striae, skin atrophy Endocrine: Suppression of HPA function due to systemic absorption; more common with long-term use Local: Infections, especially fungal; glaucoma, cataracts with long-term use

Ophthalmic preparations

Interactions

Drug-drug • Increased therapeutic and toxic effects of dexamethasone with troleandomycin • Decreased effects of anticholinesterases with corticotropin; profound muscular depression is possible • Decreased steroid blood levels with phenytoin, phenobarbital, rifampin • Decreased serum levels of salicylates with dexamethasone Drug-lab test • False-negative nitroblue-tetrazolium test for bacterial infection • Suppression of skin test reactions
Nursing considerations Assessment

History for systemic administration: Active infections; renal or hepatic disease; hypothyroidism, ulcerative colitis; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation For ophthalmic preparations: acute superficial herpes simplex keratitis, fungal infections of ocular structures; vaccinia, varicella, and other viral diseases of the cornea and conjunctiva; ocular tuberculosis Physical for systemic administration: Baseline body weight, temperature; reflexes, and grip strength, affect, and orientation; P, BP, peripheral perfusion, prominence of superficial veins; R and adventitious sounds; serum electrolytes, blood glucose For topical dermatologic preparations: affected area for infections, skin injury For systemic administration, do not give drug to nursing mothers; drug is secreted in breast milk. Give daily doses before 9 AM to mimic normal peak corticosteroid blood levels. Increase dosage when patient is subject to stress. Taper doses when discontinuing high-dose or long-term therapy. Do not give live virus vaccines with immunosuppressive doses of corticosteroids. For respiratory inhalant, intranasal preparation, do not use respiratory inhalant during an acute asthmatic attack or to manage status asthmaticus.

Interventions

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Do not use intranasal product with untreated local nasal infections, epistaxis, nasal trauma, septal ulcers, or recent nasal surgery. Taper systemic steroids carefully during transfer to inhalational steroids; adrenal insufficiency deaths have occurred. For topical dermatologic preparations, use caution when occlusive dressings, tight diapers cover affected area; these can increase systemic absorption. Avoid prolonged use near the eyes, in genital and rectal areas, and in skin creases.

Teaching points Systemic administration

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Do not stop taking the oral drug without consulting health care provider. Avoid exposure to infection. Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of this disorder. Do not overuse joint after therapy, even if pain is gone. Do not use more often than prescribed. Do not stop using this drug without consulting health care provider. Use the inhalational bronchodilator drug before using the oral inhalant product when using both. Administer decongestant nose drops first if nasal passages are blocked. Apply the drug sparingly. Avoid contact with eyes. Report any irritation or infection at the site of application. Administer as follows: Lie down or tilt head backward and look at ceiling. Warm tube of ointment in hand for several minutes. Apply one-fourth to one-half inch of ointment, or drop suspension inside lower eyelid while looking up. After applying ointment, close eyelids and roll eyeball in all directions. After instilling eye drops, release lower lid, but do not blink for at least 30 sec; apply gentle pressure to the inside corner of the eye for 1 min. Do not close eyes tightly, and try not to blink more often than usual; do not touch ointment tube or dropper to eye, fingers, or any surface. Wait at least 10 min before using any other eye preparations. Eyes will become more sensitive to light (use sunglasses). Report worsening of the condition, pain, itching, swelling of the eye, failure of the condition to improve after 1 wk.

Intra-articular administration

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Topical

Respiratory inhalant, intranasal preparation

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Ophthalmic

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Adverse effects in Italic are most common; those in Bold are life-threatening.