Formulary
Dexamethasone: Indications, Dosing, Side Effects and Interactions
Dexamethasone has very high glucocorticoid activity and insignificant mineralocorticoid activity.
MedNext Academy | 13 min read
Dexamethasone: Indications, Dosing, Side Effects and Interactions
Dexamethasone has very high glucocorticoid activity and insignificant mineralocorticoid activity.
Drug action
Dexamethasone has very high glucocorticoid activity and insignificant mineralocorticoid activity.
Indications and dose
**Suppression of inflammatory and allergic disorders**
- **Adult** (By Mouth): 0.5-10 mg daily.
**Local treatment of inflammation (short-term)**
- **Child** (To The Eye Using Eye Drop): Apply 4-6 times a day.
- **Adult** (To The Eye Using Eye Drop): Apply every 30-60 minutes until controlled, then reduced to 4-6 times a day.
**Short term local treatment of inflammation (severe conditions)**
- **Child** (To The Eye Using Eye Drop): Apply every 30-60 minutes until controlled, reduce frequency when control achieved.
**Mild croup**
- **Child** (By Mouth): 150 micrograms/kg for 1 dose.
**Congenital adrenal hyperplasia (under expert supervision)**
- **Adult** (By Mouth): Consult specialist for advice on dosing.
- **Adult** (By Intramuscular Injection, Or By Slow Intravenous Injection, Or By Intravenous Infusion): Consult specialist for advice on dosing.
**Overnight dexamethasone suppression test**
- **Adult** (By Mouth): 1 mg for 1 dose, to be given at night.
**Adjunctive treatment of suspected bacterial meningitis**
- **Adult** (By Intravenous Injection): 10 mg every 6 hours, to be started before or up to 12 hours after the first dose of antibacterial-seek specialist advice if more than 12 hours have elapsed after starting antibacterials, continued for 4 days in patients with meningitis caused by Streptococcus pneumoniae (pneumococcus) or Haemophilus influenzae type b-discontinue treatment if another cause is suspected or confirmed.
**Adjunct in the treatment of nausea and vomiting in palliative care**
- **Adult** (By Mouth): 8-16 mg daily.
**Cerebral oedema associated with brain tumours**
- **Adult** (By Mouth): Initially 8.3 mg for 1 dose, then (by intramuscular injection) 3.3 mg every 6 hours until symptoms subside, subsequently, dose may be reduced after 2-4 days and then gradually discontinued over 5-7 days.
**Life-threatening cerebral oedema**
- **Adult** (By Intravenous Injection): Initially 41.5 mg for 1 dose, then 6.6 mg every 2 hours for 3 days, then 3.3 mg every 2 hours for 1 day, then 3.3 mg every 4 hours for 4 days, dose then reduced in steps of 3.3 mg per day, continue dose reduction to discontinue over the following 7-10 days or change to oral dexamethasone maintenance if required.
**COVID-19 requiring supplemental oxygen**
- **Adult** (By Mouth, Or By Intravenous Injection): 6 mg once daily for 10 days, or until the day of discharge if this is sooner.
**Reduction of peri- and neonatal morbidity and mortality [in established preterm labour, planned preterm birth, or preterm prelabour rupture of membranes]**
- **Adult** (By Intramuscular Injection): 4.95 mg every 12 hours for 48 hours, to be given within 7 days prior to birth, treatment course may be repeated once as clinically indicated at least 7 days after completion of the first course, alternatively 9.9 mg every 24 hours for 48 hours, to be given within 7 days prior to birth, treatment course may be repeated once as clinically indicated at least 7 days after completion of the first course.
**Local treatment of inflammation [short-term]**
- **Child** (To The Eye Using Eye Drop): 13-17 years Apply 1 drop 3-4 times a day, dose to be adjusted according to response.
- **Adult** (To The Eye Using Eye Drop): Apply 1 drop 3-4 times a day, dose to be adjusted according to response.
**Physiological replacement for dexamethasone**
- **Child** (By mouth, or by slow intravenous injection): 250-500 micrograms/m2 every 12 hours, to be adjusted according to response.
**Suppression of inflammatory and allergic disorders for dexamethasone**
- **Child** (By mouth): 10-100 micrograms/kg daily in 1-2 divided doses, adjusted according to response; up to 300 micrograms/kg daily may be required in emergency situations.
- **Child 1 month-11 years** (By intramuscular injection, or by slow intravenous injection, or by intravenous infusion): 83-333 micrograms/kg daily in 1-2 divided doses; maximum 20 mg per day.
- **Child 12-17 years** (By intramuscular injection, or by slow intravenous injection, or by intravenous infusion): Initially 0.4-20 mg daily.
**Local treatment of inflammation (short-term) for dexamethasone**
- **Child** (To the eye using eye drop): Apply 4-6 times a day.
**Short term local treatment of inflammation (severe conditions) for dexamethasone**
- **Child** (To the eye using eye drop): Apply every 30-60 minutes until controlled, reduce frequency when control achieved.
**Mild croup for dexamethasone**
- **Child** (By mouth): 150 micrograms/kg for 1 dose.
**Severe croup (or mild croup that might cause complications) for dexamethasone**
- **Child** (Initially by mouth): Initially 150 micrograms/kg for 1 dose, to be given before transfer to hospital, then (by mouth or by intravenous injection) 150 micrograms/kg for 1 dose, then (by mouth or by intravenous injection) 150 micrograms/kg for 1 dose, to be given 12 hours after previous dose if required.
**Adjunctive treatment of suspected bacterial meningitis for dexamethasone**
- **Child 3 months-15 years** (By intravenous injection): 150 micrograms/kg every 6 hours (max. per dose 10 mg), to be started before or up to 12 hours after the first dose of antibacterial-seek specialist advice if more than 12 hours have elapsed after starting antibacterials, continued for 4 days in patients with meningitis caused by Streptococcus pneumoniae (pneumococcus) or Haemophilus influenzae type b-discontinue treatment if another cause is suspected or confirmed.
- **Child 16-17 years** (By intravenous injection): 10 mg every 6 hours, to be started before or up to 12 hours after the first dose of antibacterial-seek specialist advice if more than 12 hours have elapsed after starting antibacterials, continued for 4 days in patients with meningitis caused by Streptococcus pneumoniae (pneumococcus) or Haemophilus influenzae type b-discontinue treatment if another cause is suspected or confirmed.
**Life-threatening cerebral oedema for dexamethasone**
- **Child (body-weight up to 35 kg)** (By intravenous injection): Initially 16.6 mg for 1 dose, then 3.3 mg every 3 hours for 3 days, then 3.3 mg every 6 hours for 1 day, then 1.7 mg every 6 hours for 4 days, dose then reduced in steps of 0.83 mg per day, continue dose reduction to discontinue over the following 7-10 days or change to oral dexamethasone maintenance if required.
- **Child (body-weight 35 kg and above)** (By intravenous injection): Initially 20.8 mg for 1 dose, then 3.3 mg every 2 hours for 3 days, then 3.3 mg every 4 hours for 1 day, then 3.3 mg every 6 hours for 4 days, dose then reduced in steps of 1.7 mg per day, continue dose reduction to discontinue over the following 7-10 days or change to oral dexamethasone maintenance if required.
**COVID-19 requiring supplemental oxygen for dexamethasone**
- **Child** (By mouth, or by nasogastric tube, or by intravenous injection): 150 micrograms/kg once daily (max. per dose 6 mg) for 10 days, or until the day of discharge if this is sooner.
**Local treatment of inflammation [short-term] for Etacortilen**
- **Child 13-17 years** (To the eye using eye drop): Apply 1 drop 3-4 times a day, dose to be adjusted according to response.
Cautions
For all corticosteroids (systemic) Congestive heart failure; diabetes mellitus (including a family history of); diverticular disease (increased risk of diverticular perforation); diverticulitis; epilepsy; glaucoma (including a family history of or susceptibility to); history of steroid myopathy; history of tuberculosis or X-ray changes (frequent monitoring required); hypertension; hypothyroidism; infection (particularly untreated); long-term use; myasthenia gravis; ocular herpes simplex (risk of corneal perforation); osteoporosis (in children); osteoporosis (postmenopausal women and the elderly at risk) (in adults); peptic ulcer; psychiatric reactions; recent intestinal anastomoses; recent myocardial infarction (rupture reported); severe affective disorders (particularly if history of steroid-induced psychosis); thromboembolic disorders; ulcerative colitis Cautions, further information With intra-articular use or intradermal use or intralesional use: For further information on cautions associated with intra-articular, intradermal, and intralesional preparations, consult product literature. Elderly In adults: Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information). Potentially inappropriate: if used instead of inhaled corticosteroids for maintenance therapy in moderate to severe COPD (unnecessary exposure to long-term side-effects) as long-term (longer than 3 months) monotherapy for rheumatoid arthritis (risk of side-effects) for treatment of osteoarthritis other than for periodic intra-articular injections for monoarticular pain (risk of side-effects) with concurrent NSAIDs without proton pump inhibitor prophylaxis (increased risk of peptic ulcer disease) Cautions For dexamethasone When used by eye Concomitant use of ocular NSAIDs With intravitreal use History of ocular viral infection (including herpes simplex) (in adults); posterior capsule tear or iris defect (risk of implant migration into the anterior chamber which may cause corneal oedema and, in persistent severe cases, the need for corneal transplantation) (in adults); retinal vein occlusion with significant retinal ischaemia (in adults) Cautions, further information Concomitant use of ocular NSAIDs When used by eye: Concomitant use of ocular formulations containing corticosteroids with ocular formulations containing NSAIDs may increase the risk of corneal healing problems, leading to corneal melt or scarring and loss of vision. M
Contraindications
For all corticosteroids (systemic) Avoid live virus vaccines in those receiving immunosuppressive doses (serum antibody response diminished); systemic infection (unless specific therapy given) Contra-indications, further information With intra-articular use or intradermal use or intralesional use: For further information on contra-indications associated with intra-articular, intradermal and intralesional preparations, consult product literature. Contra-indications For dexamethasone With intravitreal use Active ocular herpes simplex (in adults); active or suspected ocular infection (in adults); active or suspected periocular infection (in adults); rupture of the posterior lens capsule in patients with aphakia, iris or transscleral fixated intra-ocular lens or anterior chamber intra-ocular lens (in adults); uncontrolled advanced glaucoma (in adults)
Side effects
For all corticosteroids (systemic) Common or very common Anxiety; appetite increased; behaviour abnormal; cataract subcapsular; cognitive impairment; Cushing's syndrome; electrolyte imbalance; fluid retention; gastrointestinal discomfort; headache; healing impaired; hirsutism; hypertension; increased risk of infection; menstrual cycle irregularities; mood altered; nausea; osteoporosis; peptic ulcer; psychotic disorder; skin reactions; sleep disorder; vision blurred; weight increased Uncommon Adrenal suppression; alkalosis hypokalaemic; bone fractures; diabetic control impaired; glaucoma; haemorrhage; heart failure; hyperhidrosis; leucocytosis; myopathy; osteonecrosis; pancreatitis; papilloedema; seizure; thromboembolism; tuberculosis reactivation; vertigo Rare or very rare Tendon rupture Frequency not known Chorioretinopathy; eye disorders; growth retardation (very common in children); intracranial pressure increased with papilloedema (usually after withdrawal) Side-effects, further information Adrenal suppression During prolonged therapy with corticosteroids, particularly with systemic use, adrenal atrophy develops and can persist for years after stopping. Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension, or death. To compensate for a diminished adrenocortical response caused by prolonged corticosteroid treatment, any significant intercurrent illness, trauma, or surgical procedure requires a temporary increase in corticosteroid dose, or if already stopped, a temporary reintroduction of corticosteroid treatment. For vamorolone, there is no evidence on the effects of increasing the dose, and temporary supplementation with hydrocortisone is advised. Infections Prolonged courses of corticosteroids increase susceptibility to infections and severity of infections; clinical presentation of infections may also be atypical. Serious infections e.g. septicaemia and tuberculosis may reach an advanced stage before being recognised, and amoebiasis or strongyloidiasis may be activated or exacerbated (exclude before initiating a corticosteroid in those at risk or with suggestive symptoms). Fungal or viral ocular infections may also be exacerbated. Chickenpox Unless they have had chickenpox, patients receiving oral or parenteral corticosteroids for purposes other than replacement should be regarded as being at risk of severe chickenpox. Manifestations of fulminant illness include pneumonia, hepatitis and disseminated intravascular coagulation; rash is not necessarily a prominent feature. Passive immunisation with varicella-zoster immunoglobulin is needed for exposed non-immune patients receiving systemic corticosteroids or for those who have used them within the previous 3 months. Confirmed chickenpox warrants specialist care and urgent treatment. Corticosteroids should not be stopped and dosage may need to be increased. Measles Patients taking corticosteroids should be advised to take particular care to avoid exposure to measles and to seek immediate medical advice if exposure occurs. Prophylaxis with intramuscular normal immunoglobulin may be needed. Psychiatric reactions Systemic corticosteroids, particularly in high doses, are linked to psychiatric reactions including euphoria, insomnia, irritability, mood lability, suicidal thoughts, psychotic reactions, and behavioural disturbances. These reactions frequently subside on reducing the dose or discontinuing the corticosteroid but they may also require specific management. Patients should be advised to seek medical advice if psychiatric symptoms (especially depression and suicidal thoughts) occur and they should also be alert to the rare possibility of such reactions during withdrawal of corticosteroid treatment. Systemic corticosteroids should be prescribed with care in those predisposed to psychiatric reactions, including those who have previously suffered corticosteroid-induced psychosis, or who have a personal or family history of psychiatric disorders. When used by eye (topical) Vision disorders can occur with use of topical (eye) corticosteroids. Consider seeking specialist advice to evaluate cause if vision blurred or other vision disorder occurs. Side-effects For dexamethasone Common or very common When used by eye (topical) Eye discomfort With intravitreal use Eye discomfort Uncommon When used by eye (topical) Dry eye; posterior subcapsular cataract; taste altered; vision disorders With intravitreal use Necrotising retinitis Rare or very rare When used by eye (topical) Eye inflammation; face oedema Frequency not known When used by eye (topical) Dizziness With oral use Hiccups; hyperglycaemia; hypotension; malaise; myocardial rupture (following recent myocardial infarction); protein catabolism; telangiectasia With parenteral use Hypotension; perineal irritation (may occur following the intravenous injection of large doses of the phosphate ester); telangiectasia Side-effects, further information Since systemic absorption can follow intravitreal use or topical administration to the eye, also consider the side-effects of systemic corticosteroids.
Interactions
**Other interactions (3):**
- Following topical otic administration in paediatric patients with patent tympanostomy tubes, low plasma concentrations were observed for ciprofloxacin ( 0.50 ng/ml in only 4 of 25 patients) and for...
- However, the systemic administration of some quinolones has been shown to enhance the effects of the oral anticoagulant, warfarin, and its derivatives, and has been associated with transient...
- Oral administration of ciprofloxacin has been shown to inhibit cytochrome P450 CYP1A2 and CYP3A4 isozymes, and alter the metabolism of methylxanthine compounds (caffeine, theophylline).
Pregnancy
For all corticosteroids (systemic) The benefit of treatment with corticosteroids during pregnancy outweighs the risk. Corticosteroid cover is required during labour. Following a review of the data on the safety of systemic corticosteroids used in pregnancy and breast-feeding the CSM (May 1998) concluded that corticosteroids vary in their ability to cross the placenta but there is no convincing evidence that systemic corticosteroids increase the incidence of congenital abnormalities such as cleft palate or lip. When administration is prolonged or repeated during pregnancy, systemic corticosteroids increase the risk of intra-uterine growth restriction; there is no evidence of intra-uterine growth restriction following short-term treatment (e.g. prophylactic treatment for neonatal respiratory distress syndrome). Any adrenal suppression in the neonate following prenatal exposure usually resolves spontaneously after birth and is rarely clinically important. Monitoring in pregnancy Pregnant women with pre-eclampsia or fluid retention should be monitored closely when given systemic corticosteroids. Pregnancy For dexamethasone Dexamethasone readily crosses the placenta. With intravitreal use in adults: Manufacturer advises avoid unless potential benefit outweighs risk-no information available.
Breast feeding
For all corticosteroids (systemic) The benefit of treatment with corticosteroids during breast-feeding outweighs the risk. Breast feeding For dexamethasone With intravitreal use in adults: Manufacturer advises avoid unless potential benefit outweighs risk-no information available.
Hepatic impairment
For all corticosteroids (systemic) In general, manufacturers advise caution (risk of increased exposure).
Renal impairment
For all corticosteroids (systemic) In general, manufacturers advise caution.
Medicinal forms
Capsule,Tablet,Tablet,Solution,Solution,Drops
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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