Functional class
Func. class.: Corticosteroid, synthetic
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Drug reference
Func. class.: Corticosteroid, synthetic
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Chem. class.: Glucocorticoid, long acting
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ACTION: Decreases inflammation by suppression of migration of polymorpho- nuclear leukocytes, fibroblasts, reversal of increased capillary permeability and lysosomal stabilization, suppresses nor- mal immune response, no mineralocorti- coid effects
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USES: Inflammation, allergies, neo- plasms, cerebral edema, septic shock, collagen disorders, dexamethasone suppression test for Cushing syndrome, adrenocortical insufficiency, TB, menin- gitis, acute exacerbations of MS
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CONTRAINDICATIONS: Hyper- sensitivity to corticosteroids, sulfites, or benzyl alcohol; fungal infections, abrupt discontinuation, coagulopathy, ulcerative colitis, seizure disorders Precautions: Pregnancy, breastfeeding, diabetes mellitus, osteoporosis, seizure disorders, ulcerative colitis, HF, myas- thenia gravis, renal disease, peptic ulcer, esophagitis, recent MI, hyperten- sion, TB, active hepatitis, psychosis, sulfite hypersensitivity, thromboembolic disorders
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SIDE EFFECTS CNS: Depression, headache, mood changes, euphoria, pseudotumor cerebi, seizures CV: Hypertension EENT: Increased intraocular pressure, cataracts ENDO: HPA suppression, hyperglycemia, sodium, fluid retention, pheochromocytoma GI: Nausea, peptic ulceration, vomiting, weight gain INTEG: Acne, poor wound healing, ecchymosis, petechiae, hirsutism META: Hypokalemia, fluid retention, hypokalemic alkalosis MS: Fractures, osteoporosis, weakness, arthralgia, myopathy
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INTERACTIONS Increase: toxicity—cycloSPORINE, moni- tor closely Increase: side effects—alcohol, salicy- lates, amphotericin B, digoxin, cycloSPO- RINE, diuretics, NSAIDs, monitor closely Increase: dexamethasone action—salic- ylates, estrogens, hormonal contracep- tives, ketoconazole, macrolide antiinfec- tives, NSAIDs Increase: tendinitis, tendon rupture risk—quinolones Decrease: effect of—antidiabetics, insulin dose may need to be increased Decrease: dexamethasone action— cholestyramine, colestipol, barbiturates, rifAMPin, phenytoin, theophylline, antac- ids, bosentan, carBAMazepine Decrease: anticoagulant effect— anticonvulsants, antidiabetics, isoniazid, toxoids, anticholinesterases, salicylates Decrease: potassium levels—thiazide/ loop diuretics, amphotericin B Decrease: antibody response—vaccines, avoid using concurrently Drug/Herb Decrease: dexamethasone action—echi- nacea, avoid using together Drug/Lab Test Increase: cholesterol, sodium, blood glucose Decrease: calcium, potassium, T4, T3, thyroid 131I uptake test False negative: skin allergy tests
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DOSAGE AND ROUTES Inflammatory condition/neoplasias • Adult: PO 0.75-9 mg/day in divided doses q6-12hr or phosphate IM 0.5-9 mg/day divided q6-12hr • Child: PO 0.024-0.34 mg/kg/day in divided doses q6-12hr Anaphylactic shock • Adult: IV (phosphate) single dose 1-6 mg/kg or IV 40 mg q2-6hr as needed up to 72 hr Airway edema/extubation • Adult: PO/IM/IV 0.5-2 mg/kg/day divided q6hr; use 24 hr before extubation and use for 24 hr after ex- tubation Chemotherapy-induced vomiting • Adult: PO/IV 10-20 mg 15-30 min prior to chemotherapy or 10 mg q12hr on each treatment day • Child: IV 5-20 mg 15-30 min prior to chemotherapy Cerebral edema • Adult: IV (phosphate) 10 mg, then 4-6 mg IM q6hr × 2-4 days, then taper over 1 wk • Child: loading dose 1-2 mg/kg (PO/ IM/IV), then 1-1.5 mg/kg/day, max 16 mg/day divided q4-6hr for 2-4 days, then taper down weekly Cushing syndrome (suppression test) Adult: PO 0.5 mg q6hr × 48 hr (after deter- mining 24-hr 17 hydroxycorticosteroids urine level); repeat urine collection to determine levels during 24 hr or 1 mg at 11 PM and draw plasma cortisol at 8 AM next morning Palliative management of recurrent or inoperable brain tumors • Adult: IM/IV 2 mg bid-tid (maintenance) Adrenocortical insufficiency D • Adult: PO 0.75-9 mg/day in divided doses • Child: PO 0.03-0.3 mg/kg/day in 2-4 divided doses Intraarticular/intralesional Adult: PO 0.2-6 mg daily to q3days, de- pends on condition
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Available forms: Tablets 0.5, 0.75, 1, 1.5, 2, 4, 6 mg; oral solution 0.5 mg/5 mL; elixir 0.5 mg/5 mL, oral concentrate 1 mg/mL; injection 4 mg/mL, 10 mg/mL
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Administer: PO route • Titrated dose; use lowest effective dose • With food or milk to decrease GI symptoms, give once daily in AM for less toxicity, fewer adverse reactions IM route • IM injection deeply in large muscle mass; rotate sites; avoid deltoid; use 21-G needle • In 1 dose in AM to prevent adrenal suppression; avoid SUBCUT administra- tion, may damage tissue Intra-articular/intralesional route • Use rarely, as injections may damage joints Direct IV route (sodium phosphate) • Undiluted direct over ≥1 min Intermittent IV INFUSION route • Diluted with 0.9% NaCl or D5W, give as IV infusion at prescribed rate Continuous IV infusion • Change IV solution q24hr Y-site compatibilities: Acetaminophen, acyclovir, alfentanil, allopurinol, amifostine, amikacin, aminocaproic acid, aminophyl- line, amphotericin B cholesteryl, ampho- tericin B lipid complex, amphotericin B liposome, amsacrine, anidulafungin, arg- atroban, ascorbic acid injection, atenolol, atracurium, atropine, aztreonam, benztro- pine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, caffeine, CARBOplatin, carmustine, ceFAZolin, cefepime, cefmetazole, cefonicid, cefotaxime, cefoTEtan, cefOXitin, cefpi- rome, ceftaroline, cefTAZidime, ceftizox- ime, cefTRIAXone, chloramphenicol, cimetidine, cisatracurium, CISplatin, cladribine, clindamycin, codeine, cyanoco- balamin, cyclophosphamide, cycloSPO- RINE, cytarabine, DACTINomycin, DAPTO- mycin, DAUNOrubicin, dexmedetomidine, digoxin, diltiazem, DOCEtaxel, DOPamine, doripenem, doxacurium, DOXOrubicin, DOXOrubicin liposomal, enalaprilat, ePHEDrine, EPINEPHrine, epoetin alfa, eptifibatide, ertapenem, etoposide, etopo- side phosphate, famotidine, fentaNYL, fil- grastim, fluconazole, fludarabine, fluoro- uracil, folic acid, fosaprepitant, foscarnet, furosemide, ganciclovir, gatifloxacin, gem- citabine, glycopyrrolate, granisetron, hepa- rin, hydrocortisone, HYDROmorphone, ifosfamide, imipenem-cilastatin, indometh- acin, insulin (regular), irinotecan, isopro- terenol, ketorolac, lansoprazole, leucovo- rin, levofloxacin, lidocaine, linezolid, liposome, LORazepam, LR, mannitol, mechlorethamine, melphalan, merope- nem, metaraminol, methadone, methicillin, methoxamine, methyldopate, methylPRED- NISolone, metoclopramide, metoprolol, metroNIDAZOLE, mezlocillin, miconazole, milrinone, morphine, multiple vitamins injection, nafcillin, nalbuphine, naloxone, nitroglycerin, nitroprusside, norepineph- rine, octreotide, ondansetron, oxacillin, oxaliplatin, oxyCODONE, oxytocin, PACLi- taxel, palonosetron, pamidronate, pan- curonium, PEMEtrexed, penicillin G potas- sium/sodium, PENTobarbital, PHENobarbital, phenylephrine, phytonadi- one, piperacillin, piperacillin-tazobactam, potassium chloride, procainamide, propo- fol, propranolol, pyridoxine, ranitidine, remifentanil, Ringer’s, ritodrine, riTUX- imab, sargramostim, sodium acetate/bicar- bonate, succinylcholine, SUFentanil, tacro- limus, telavancin, teniposide, theophylline, thiamine, thiotepa, ticarcillin, ticarcillin- clavulanate, tigecycline, tirofiban, TNA, tolazoline, topotecan, trastuzumab, uroki- nase, vancomycin, vasopressin, vecuronium, verapamil, vinCRIStine, vinorelbine, vitamin B complex/C, voricon- azole, zidovudine, zoledronic acid
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Assess: • Potassium, blood, urine glucose while receiving long-term therapy; hypo/hyper- glycemia, weight daily; notify prescriber of weekly gain >5 lb, B/P, pulse; notify prescriber of chest pain • I&O ratio; be alert for decreasing uri- nary output, increasing edema • Cerebral edema: LOC and head- ache, baseline and periodically • Adrenal insufficiency: weight loss, nausea, vomiting, anorexia, confusion, decreased B/P, baseline and periodically • Epidural injections (unlabeled): may cause rare events (vision loss, paralysis, stroke, death) • Cushingoid symptoms: assess for buffalo hump, moon face, increased B/P; monitor plasma cortisol levels during long- term therapy (normal: 138-635 nmol/L SI units when drawn at 8 AM); prolonged use can cause cushingoid symptoms • Infection: fever, WBC even after with- drawal of medication; product masks in- fection • Potassium depletion: paresthesias, fatigue, nausea, vomiting, depression, polyuria, dysrhythmias, weakness • Edema, hypertension, cardiac symptoms • Mental status: affect, mood, behav- ioral changes, aggression • Abrupt withdrawal: acute adrenal insufficiency and death may occur follow- ing abrupt discontinuation of systemic therapy; withdraw gradually • Pregnancy/breastfeeding: no well- controlled studies; use only if benefit outweighs fetal risk; discontinue breast- feeding or product
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Evaluate: • Therapeutic response: decreased in- flammation
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • To carry medical alert ID as cortico- D steroid user at all times • To contact prescriber if surgery, trauma, stress occurs because dose may need to be adjusted • To notify prescriber if therapeutic re- sponse decreases because dosage adjust- ment may be needed • To take with food or milk • That bruising may occur easily • That if on long-term therapy, a high- protein diet may be needed • Not to discontinue abruptly because adrenal crisis can result • About symptoms of adrenal insuffi- ciency: nausea, anorexia, fatigue, dizzi- ness, dyspnea, weakness, joint pain, hypertension • To avoid OTC products: salicylates, alcohol in cough products, cold prepara- tions unless directed by prescriber • About all aspects of product usage, including cushingoid symptoms; to notify health care provider of infec- tion • To avoid exposure to chickenpox or measles, persons with infection
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PHARMACOKINETICS Half-life 1-2 days PO: Onset 1 hr, peak 1-2 hr, duration 2½ days IM: Onset 1 hr, peak 1 hr, duration 2 days-3 wk IV: Onset 1 hr, peak 1 hr, duration varies
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• Adult: PO 0.75-9 mg/day in divided doses q6-12hr or phosphate IM 0.5-9 mg/day divided q6-12hr
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• Child: PO 0.024-0.34 mg/kg/day in divided doses q6-12hr Anaphylactic shock
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• Adult: IV (phosphate) single dose 1-6 mg/kg or IV 40 mg q2-6hr as needed up to 72 hr Airway edema/extubation
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• Adult: PO/IM/IV 0.5-2 mg/kg/day divided q6hr; use 24 hr before extubation and use for 24 hr after ex- tubation Chemotherapy-induced vomiting
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• Adult: PO/IV 10-20 mg 15-30 min prior to chemotherapy or 10 mg q12hr on each treatment day
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• Child: IV 5-20 mg 15-30 min prior to chemotherapy Cerebral edema
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• Adult: IV (phosphate) 10 mg, then 4-6 mg IM q6hr × 2-4 days, then taper over 1 wk
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• Child: loading dose 1-2 mg/kg (PO/ IM/IV), then 1-1.5 mg/kg/day, max 16 mg/day divided q4-6hr for 2-4 days, then taper down weekly Cushing syndrome (suppression test) Adult: PO 0.5 mg q6hr × 48 hr (after deter- mining 24-hr 17 hydroxycorticosteroids urine level); repeat urine collection to determine levels during 24 hr or 1 mg at 11 PM and draw plasma cortisol at 8 AM next morning Palliative management of recurrent or inoperable brain tumors
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• Adult: IM/IV 2 mg bid-tid (maintenance) Adrenocortical insufficiency D
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• Adult: PO 0.75-9 mg/day in divided doses
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• Child: PO 0.03-0.3 mg/kg/day in 2-4 divided doses Intraarticular/intralesional Adult: PO 0.2-6 mg daily to q3days, de- pends on condition
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