Dexamethasone has been shown to reduce mortality in hospitalised patients with COVID-19 that require mechanical ventilation, supplementary oxygen (see NHS England Clinical Guidance), or Extra Corporeal Membrane Oxygenation (ECMO).
Up to 10 days of dexamethasone 6mg daily (taken orally or by intravenous injection) is recommended. If the patient is discharged from hospital before the end of 10 days, dexamethasone prescribed for COVID-19 should be stopped and this should be stated on the discharge summary.
It is not yet known what impact dexamethasone has on mortality in hospitalised patients other than the group described above. Preliminary results from the RECOVERY trial did not rule out the possibility that dexamethasone could increase mortality for some cohorts.
There is no evidence to support the use of dexamethasone in patients with COVID-19 that do not require hospitalisation.
Additional information is also available in a CAS Alert issued on 16th June 2020.
Further information on all aspects of the RECOVERY trial is available here.
What is known about the current role of dexamethasone in COVID-19?
Basis of recommendation for patient group that will benefit
The recommendation for patients that will benefit from dexamethasone was based on the unpublished results of one arm of the RECOVERY trial, subsequently made available as a preliminary report. Further detail on the RECOVERY trial is available here.
Considerations for specific patient groups and co-prescribing
Gastroprotection and PPIs
In the RECOVERY trial patients were only excluded if dexamethasone was contra-indicated, which in practice would include patients with known hypersensitivity and perhaps patients with active GI ulcers.
The protocol for the RECOVERY trial did not stipulate whether GI protection should be prescribed routinely. Thus there is not definitive advice on concomitant gastroprotection.
Where there is history of GI ulceration or patients are at higher risk of bleed (e.g. concurrent thromboprophylaxis), consider gastroprotection for the duration of the corticosteroid course.
A meta-analysis of 61 clinical trials assessing the role of corticosteroids in sepsis concluded that corticosteroids increase the risk of muscle weakness and hypernatraemia. However, the analysis concerned doses of corticosteroids that were not reflective of the dose used in the RECOVERY trial.
Corticosteroids probably increase the risk of hyperglycaemia. The patient group is more likely to have suboptimally controlled diabetes, and the addition of dexamethasone may make blood glucose control particularly challenging; further advice is available here. Input from a Diabetes Team may therefore be warranted to improve blood glucose control on a case-by-case basis.
Concomitant use of remdesivir
Remdesivir was not available whilst recruitment was active for the arm of the RECOVERY trial that has now been reported; it is therefore not possible to compare treatment effectiveness. The CAS Alert advises that coadministration with dexamethasone and remdesivir has not been studied, but based on metabolism and clearance a clinically significant interaction is unlikely. Further information on the potential for an interaction is provided by the University of Liverpool COVID-19 Drug Interactions checker.
Pregnancy and breast-feeding
Although pregnant and breastfeeding women were eligible for study inclusion, none received dexamethasone. Either oral prednisolone 40 mg once daily or intravenous hydrocortisone 80 mg twice daily are recommended during pregnancy or breastfeeding.
How should dexamethasone be administered?
Dexamethasone should be prescribed as the base salt and can be given in any of the following formulations:
- Dexamethasone solution for injection (available as 3.3mg/mL and 3.8mg/mL strengths: 1.8mL of the 3.3mg/mL gives the dose required; 1.6mL of the 3.8mg/mL gives the dose required. See Medusa injectable medicines guide for further information)
- Dexamethasone tablets (available in 2mg and 4mg strengths)
- Dexamethasone soluble tablets (available in 2mg and 4mg strengths)
- Dexamethasone oral liquid (available as 2mg/5mL or 2mg/1mL strengths)
About this page
This page was developed in conjunction with:
- Greg Barton, Specialist Pharmacist: Critical Care and Burns, St Helens and Knowsley Teaching Hospitals NHS Trust
- Mark Borthwick, Consultant Pharmacist: Critical Care, Oxford University Hospitals NHS Foundation Trust
- Dr Richard S Bourne, Consultant Pharmacist: Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust
- Gráinne d’Ancona, Consultant Pharmacist: Respiratory and Sleep Medicine, Guy’s and St. Thomas’ NHS Foundation Trust
- Anna Murphy, Consultant Pharmacist: Respiratory, University Hospitals of Leicester NHS Trust
We are hugely grateful for their input.
This page has been developed quickly in response to the COVID-19 pandemic; if you spot anything that’s wrong report a concern to us.