weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture, vertebral compression fractures Neurological/Psychiatric: Convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema (pseudotumor cerebri) usually following discontinuation of treatment, insomnia, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychic disorders, vertigo Ophthalmic: Exophthalmos, glaucoma, increased intraocular pressure, posterior subcapsular cataracts, vision blurred Other: Abnormal fat deposits, decreased resistance to infection, hiccups, increased or decreased motility and number of spermatozoa, malaise, moon face, weight gain Contraindications Systemic fungal infection Documented hypersensitivity Cerebral malaria Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids Cautions Use with caution in cirrhosis, diverticulitis, myasthenia gravis, peptic ulcer disease, ulcerative colitis, renal insufficiency, pregnancy Average and large doses of corticosteroids can cause elevation of blood pressure, sodium and water retention, and increased excretion of potassium; these effects are less likely to occur with synthetic derivatives except when used in large doses; dietary salt restriction and potassium supplementation may be necessary; all corticosteroids increase calcium excretion Literature reports suggest apparent association between use of corticosteroids and left ventricular free wall rupture after recent myocardial infarction; therapy with corticosteroids should be used with great caution in these patients Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with potential for glucocorticosteroid insufficiency after withdrawal of treatment; adrenocortical insufficiency may result from too rapid withdrawal; may be minimized by gradual reduction of dosage; relative insufficiency may persist for months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, reinstitute hormone therapy; if patient is receiving steroids already, may increase dosage Metabolic clearance of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients; changes in thyroid status of patient may necessitate adjustment in dosage May exacerbate systemic fungal infections; not for use in presence of such infections unless needed to control life-threatening drug reactions Latent disease may be activated or there may be an exacerbation of intercurrent infections due to pathogens, including those caused by Amoeba, Candida, Cryptococcus, Mycobacterium, Nocardia, Pneumocystis, toxoplasma; rule out latent amebiasis or active amebiasis before initiating corticosteroid therapy in any patient who has spent time in the tropics or any patient with unexplained diarrhea Use with great care in patients with known or suspected Strongyloides (threadworm) infestation; corticosteroid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia; not for use in cerebral malaria Close observation necessary if corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity; reactivation of the disease may occur; during prolonged corticosteroid therapy, these patients should receive chemoprophylaxis Use of oral corticosteroids not recommended in treatment of optic neuritis and may lead to increase in risk of new episodes; corticosteroids should not be used in active ocular herpes simplex Use lowest possible dose to control condition under treatment; risk/benefit decision must be made in each individual case as to dose and duration of treatment and as to whether daily or intermittent therapy should be used May lead to inhibition of bone growth in pediatric patients and development of osteoporosis at any age; special consideration should be given to patients at increased risk of osteoporosis (e.g., postmenopausal women) before initiating corticosteroid therapy Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations; existing emotional instability or psychotic tendencies may also be aggravated by corticosteroids Minimal mineralocorticoid activity Thromboembolic disorders Myopathy has been reported Delayed wound healing Withdraw therapy with gradual tapering dose May have systemic and local effects; examine joint fluid, as necessary to exclude a septic process; avoid injection into infected site; frequent intra-articular injections may result in damage to joint tissue If exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated; if exposed to measles, prophylaxis with immune globulin (IG) may be indicated; if chickenpox develops, treatment with antiviral agents should be considered Latent tuberculosis may be reactivated (patients with positive tuberculin test should be monitored) Some suggestion (not fully substantiated) of slightly increased cleft palate risk if corticosteroids are used in pregnancy Prolonged corticosteroid use may result in elevated intraocular pressure, glaucoma, or cataracts with possible damage to optic nerves, and may enhance establishment of secondary ocular infections due to bacteria, fungi, or viruses; consider referral to ophthalmologist for patients who develop ocular symptoms or use corticosteroid-containing products for more than 6 weeks Prolonged therapy has been associated with development of Kaposi sarcoma May affect velocity growth in children; monitor routinely Patient may require higher doses when subject to stress Immunization procedures may be undertaken in patients who are receiving corticosteroids as replacement therapy in physiologic doses (eg, for Addison’s disease) Epidural injection Serious neurologic events, some resulting in death, have been reported with epidural injection Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke These serious neurologic events have been reported with and without use of fluoroscopy Safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use Drug interaction overview Strong CYP3A4 inhibitors Coadministration of strong and moderate CYP3A4 inhibitors increased dexamethasone exposure, which may increase the risk of adverse reactions Avoid coadministration of strong CYP3A4 inhibitors or consider alternatives that are not strong CYP3A4 inhibitors If coadministration cannot be avoided, closely monitor for adverse drug reactions Strong CYP3A4 inducers Coadministration of strong CYP3A4 inducers may decrease dexamethasone exposure, which may result in loss of efficacy Avoid coadministration of strong CYP3A4 inducers or consider alternative medication that are not CYP3A4 inducers If coadministration cannot be avoided, consider increasing the dexamethasone dose Cholestyramine Cholestyramine may increase clearance of corticosteroids and potentially decrease corticosteroid exposure Avoid coadministration and consider alternative agents Anticholinesterases Concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis If possible, anticholinesterase agents should be withdrawn at least 24 hr before initiating corticosteroid therapy Ephedrine Ephedrine may decrease dexamethasone exposure and may result in loss of efficacy Consider increasing the dexamethasone dose when used with ephedrine Estrogens Estrogens may decrease the hepatic metabolism of certain corticosteroids and increase exposures, which may increase the risk of adverse reactions CYP3A4 substrates Coadministration of dexamethasone with substrates may decrease the concentration of these drugs, resulting in loss of efficacy of these drugs Oral anticoagulants Coadministration of anticoagulants with corticosteroids may reduce the response to anticoagulants; frequently monitor coagulation indices to maintain the desired anticoagulant effect Amphotericin B injection and potassium-depleting agents Sodium retention with resultant edema and potassium loss may occur in patients receiving corticosteroid; closely monitor potassium levels Antidiabetics Corticosteroids may increase blood glucose concentrations; consider adjusting the dose of antidiabetic agents, as necessary Isoniazid Serum concentrations of isoniazid may be decreased with corticosteroids Cyclosporine Increased activity of both cyclosporine and corticosteroids may occur when the two are used concurrently Convulsions have been reported with this concurrent use Digitalis glycosides Patients on digitalis glycosides may be at increased risk of arrhythmias due to hypokalemia Nonsteroidal Anti-Inflammatory Agents (NSAIDS) Concomitant use of aspirin (or other NSAIDS) and corticosteroids increases the risk of gastrointestinal side effects; clearance of salicylates may be increased with concurrent use of corticosteroids; monitor for toxicity Phenytoin In postmarketing experience, there have been reports of both increases and decreases in phenytoin levels with dexamethasone coadministration, leading to alterations in seizure control Vaccines Patients on corticosteroid therapy may exhibit a diminished response to toxoids and live or inactivated vaccines due to inhibition of antibody response Corticosteroids may also potentiate the replication of some organisms contained in live attenuated vaccines If possible, defer routine administration of vaccines or toxoids until therapy is discontinued Concomitant therapies that may increase the risk of thromboembolism Erythropoietic agents, or other agents that may increase the risk of thromboembolism, such as estrogen containing therapies, coadministered with dexamethasone may increase the risk of thromboembolism; monitor for risk of thromboembolism Thalidomide Toxic epidermal necrolysis has been reported with concomitant use of thalidomide Closely monitor for toxicity Skin tests Corticosteroids may suppress reactions to skin tests Pregnancy Corticosteroids readily cross the placenta Adverse developmental outcomes including orofacial clefts (cleft lip with or without cleft palate), intrauterine growth restriction, and decreased birth weight have been reported with maternal use of corticosteroids during pregnancy Pregnancy testing is recommended for females of reproductive potential before initiating treatment Animal data In animal developmental and reproductive toxicology studies administration of corticosteroids to pregnant animals during organogenesis resulted in structural abnormalities, embryofetal mortality, functional impairment, and alterations to growth at doses equivalent to or below the recommended doses Advise pregnant women of the potential risk to a fetus Hemady is administered in combination with antimyeloma products that can cause embryofetal harm and are contraindicated for use in pregnancy (refer to prescribing information for additional information) Contraception Use effective contraception during treatment and for at least 1 month following final dose Infertility in males Steroids may increase or decrease motility and number of spermatozoa in some patients In animals, dexamethasone affects male spermatogenesis Lactation Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects Advise women not to breastfeed during treatment and for 2 weeks after the last dose Pregnancy Categories A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk. B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available. Mechanism of Action Potent glucocorticoid with minimal to no mineralocorticoid activity Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and reducing capillary permeability; stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines; suppresses lymphocyte proliferation through direct cytolysis, inhibits mitosis, breaks down granulocyte aggregates, and improves pulmonary microcirculation Absorption Onset: Between a few minutes and several hours; dependent on indication and route of administration Peak serum time: 8hr (IM); 1-2 hr (PO) Distribution Vd: 2 L/kg Metabolism Metabolized in liver Elimination Half-life: 1.8-3.5 hr (normal renal function) Excretion: Urine (mainly), feces (minimally) IV Compatibilities Solution: D5W, NS Additive: Aminophylline, bleomycin, cimetidine, floxacillin, furosemide, granisetron, lidocaine, meropenem, mitomycin, nafcillin, netilmicin, ondansetron, prochlorperazine, ranitidine, verapamil Syringe: Caffeine, granisetron, metoclopramide, ondansetron, ranitidine, sufentanil Y-site (partial list): Acyclovir, allopurinol, cisplatin, cladribine, cyclophosphamide, cytarabine, docetaxel, etoposide phosphate, famotidine, fentanyl, fluconazole, gemcitabine, heparin with hydrocortisone, linezolid, lorazepam, meperidine, morphine, potassium chloride, propofol, sodium bicarbonate, zidovudine IV Incompatibilities Additive: Amikacin(?), daunorubicin, diphenhydramine with lorazepam and metoclopramide, metaraminol, vancomycin Syringe: Diphenhydramine(?), doxapram, glycopyrrolate, hydromorphone(?) Y-site: Ciprofloxacin, fenoldopam, idarubicin, methotrexate(?), midazolam, topotecan IV Preparation Standard diluent: 4 mg/50 mL D5W or 10 mg/50 mL D5W Minimum volume: 50 mL D5W Dexamethasone 4 mg/mL injection is clear and colorless IV/IM Administration Dexamethasone sodium phosphate: Administered by IV push, continuous or intermittent IV infusion, or IM Acetate injection: Administered only IM Oral Administration For oral administration only Storage Protect from light Protect from freezing Tablets, vials, or elixir: Store at controlled room temperature 20-25ºC (68-77ºF) Hemady: Dispense in a tight, light-resistant, child-resistant container BRAND FORM. UNIT PRICE PILL IMAGE dexamethasone oral- 0.75 mg tabletdexamethasone oral- 4 mg tabletdexamethasone oral- 1.5 mg (51 tabs) tabletdexamethasone oral- 1.5 mg (35 tabs) tabletdexamethasone oral- 1.5 mg tabletdexamethasone oral- 1.5 mg tabletdexamethasone oral- 4 mg tabletdexamethasone oral- 0.5 mg/5 mL elixirdexamethasone oral- 0.5 mg/5 mL elixirdexamethasone oral- 0.5 mg/5 mL elixirdexamethasone oral- 6 mg tabletdexamethasone oral- 0.75 mg tabletdexamethasone oral- 2 mg tabletdexamethasone oral- 6 mg tabletdexamethasone oral- 1 mg tabletdexamethasone oral- 4 mg tabletdexamethasone oral- 0.5 mg tabletdexamethasone oral- 2 mg tabletdexamethasone oral- 2 mg tabletdexamethasone oral- 0.5 mg tabletdexamethasone oral- 4 mg tabletdexamethasone oral- 4 mg tabletdexamethasone oral- 1.5 mg (21 tabs) tabletdexamethasone oral- 0.5 mg/5 mL solutiondexamethasone oral- 0.5 mg/5 mL solutionDexamethasone Intensol oral- 1 mg/mL dropsMaxidex ophthalmic (eye)- 0.1 % dropsDexabliss oral- 1.5 mg (39 tabs)