dexamethasone Nursing Considerations & Management

 Drug Name

Generic Name : dexamethasone,dexamethasone acetate , dexamethasone sodium phosphate

Brand Name:

  • Oral, topical dermatologic aerosol and gel, ophthalmic suspension: Aeroseb-Dex, Decadron, Hexadrol, Maxidex Ophthalmic, ratio-Dexanamethasone (CAN)
  • IM, intra-articular, or soft-tissue injection: Cortastat LA, Dalalone L.A., Decaject LA, Dexasone-L.A., Dexone LA, Solurex LA
  • IV, IM, intra-articular, intralesional injection; respiratory inhalant; intranasal steroid; ophthalmic solution and ointment; topical dermatologic cream: Cortastat, Dalalone, Decadron Phosphate, Decaject, Dexasone, Hexadrol Phosphate, Solurex

Classification: Corticosteroid, Glucocorticoid, Hormone

Pregnancy Category C

Dosage & Route

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)

  • 0.75–9 mg/day.
  • Suppression test for Cushing’s syndrome: 1 mg at 11 AM; assay plasma cortisol at 8 AM the next day. For greater accuracy, give 0.5 mg q 6 hr for 48 hr, and collect 24-hr urine to determine 17-hydroxycorticosteroid (17-OHCS) 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-OHCS excretion.

IM (dexamethasone acetate)

  • 8–16 mg; may repeat in 1–3 wk.

IV or IM (dexamethasone sodium phosphate)

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

PEDIATRIC PATIENTS

  • 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.

IV

  • 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

ADULTS AND PEDIATRIC PATIENTS

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

ADULTS AND PEDIATRIC PATIENTS

  • 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

ADULTS AND PEDIATRIC PATIENTS

  • Apply a thin coating in the lower conjunctival sac tid–qid; reduce dosage to bid and then qid after improvement.
Therapeutic actions
  • Dexamethasone is a synthetic glucocorticoid which decreases inflammation by inhibiting the migration of leukocytes and reversal of increased capillary permeability. It suppresses normal immune response
Indications
  • 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 MS, 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
  • 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
Adverse effects
  • Growth retardation, osteoporosis, peptic ulcer, glaucoma and subcapsular cataracts, vertebral compression fractures. Cushing-like features, pancreatic dysfunction and pancreatitis, GI upsets, increased appetite, increased fragility of the skin. Increased susceptibility to infection. Topical application: Dermal atrophy, local irritation, folliculitis, delayed wound healing, systemic absorption and toxicity with occlusive dressing on application to large areas of the body and broken skin. Topical application to eye: Corneal ulcers, glaucoma and reduced visual ability. Inhalation: Hoarseness, candidiasis of mouth and throat. Intra-articular inj: Aseptic necrosis of bone and joint damage.
  • Potentially Fatal: HPA supression; CV collapse on rapid IV admin.
Contraindications
  • Hypersensitivity; active untreated infections; ophthalmic use in viral, fungal disease of the eye.
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
  • History 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 TB
  • Physical for systemic administration: Baseline body weight, T; reflexes, and grip strength, affect, and orientation; P, BP, peripheral perfusion, prominence of superficial veins; R and adventitious sounds; serum electrolytes, blood glucose
  • Physical for topical dermatologic preparations: Affected area for infections, skin injury
Interventions
  • For systemic administration, do not give drug to nursing mothers; drug is secreted in breast milk.
  • WARNING: 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.
  • Do not use intranasal product with untreated local nasal infections, epistaxis, nasal trauma, septal ulcers, or recent nasal surgery.
  • WARNING: 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

  • Do not stop taking the oral drug without consulting your 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.

Intra-articular administration

  • Do not overuse joint after therapy, even if pain is gone.

Respiratory inhalant, intranasal preparation

  • 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.

Topical

  • Apply the drug sparingly.
  • Avoid contact with eyes.
  • Report any irritation or infection at the site of application.

Ophthalmic

  • 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 seconds; apply gentle pressure to the inside corner of the eye for 1 minute. 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 minutes 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 week.