Systemic Corticosteroid Pregnancy: Use if clearly indicated — benefits likely outweigh risks in critical illness; neonatal adrenal suppression possible with prolonged use

Dexamethasone (ICU / ARDS)

Brand names: Dexamethasone 3.3 mg/mL injection

Adult dose

Dose: COVID-19/ARDS: 6 mg IV or oral once daily for up to 10 days; Post-extubation stridor: 8 mg IV at least 1 hour before planned extubation; Bacterial meningitis: 0.15 mg/kg IV every 6 hours for 4 days (with first dose of antibiotics)

Route: Intravenous or oral

Frequency: Once daily (ARDS/COVID); every 6 hours (meningitis)

Max: 8 mg/day (COVID/ARDS); 0.6 mg/kg/day (meningitis)

6 mg/day is the exact RECOVERY trial dose — do not exceed without indication; patients on oxygen/ventilation benefit most; no benefit in COVID-19 if not requiring respiratory support

Paediatric dose

Dose: 0.15 mg/kg IV every 6 hours (meningitis); ARDS: specialist guidance mg/kg

Route: Intravenous

Frequency: Every 6 hours (meningitis)

Max: 0.6 mg/kg/day

Bacterial meningitis: NICE NG240 recommends dexamethasone in children ≥3 months with suspected bacterial meningitis — within 12 hours of antibiotics

Dose adjustments

Renal

No dose adjustment required

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Patient weight (kg)

Bacterial meningitis: NICE NG240 recommends dexamethasone in children ≥3 months with suspected bacterial meningitis — within 12 hours of antibiotics

Clinical pearls

RECOVERY trial (Horby et al. NEJM 2021): dexamethasone 6 mg/day for 10 days reduced 28-day mortality in hospitalised COVID-19 patients on supplemental oxygen (relative risk 0.83) and on invasive ventilation (RR 0.64) — no benefit and possible harm in those not requiring oxygen; changed global ICU practice overnight
DEXA-ARDS trial (Villar et al. Lancet Respir Med 2020): dexamethasone 20 mg/day for 5 days then 10 mg/day for 5 days reduced 60-day mortality in ARDS (21% vs 36%) — different from COVID dose; used in non-COVID ARDS
Post-extubation stridor prophylaxis: high-risk patients (failed extubation criteria, prolonged intubation, large ETT) — dexamethasone 8 mg IV 12 and 1 hour before extubation reduces post-extubation stridor and re-intubation rate (DASICU trial)
Bacterial meningitis: dexamethasone attenuates inflammatory response to bacterial lysis from antibiotics — reduces deafness in Streptococcus pneumoniae meningitis; less benefit in Neisseria meningitidis or Gram-negative meningitis; MUST be given with or before first antibiotic dose (not after)
ICU blood glucose management: dexamethasone causes significant hyperglycaemia — target glucose 6-10 mmol/L in ICU using insulin infusion (NICE-SUGAR target); dexamethasone-induced hyperglycaemia can persist for 12-24h after dose

Contraindications

Systemic fungal infection without antifungal cover
Live vaccines during and for 3 months after treatment

Side effects

Hyperglycaemia
Hypertension
Secondary infections
GI ulceration (with NSAIDs)
Adrenal suppression (prolonged courses)
Fluid retention
Myopathy (ICU-acquired weakness)

Interactions

Insulin/antidiabetics — dose increase required
NSAIDs — additive GI toxicity
CYP3A4 inducers — reduce dexamethasone levels

Monitoring

Blood glucose (4-hourly in ICU)
Blood pressure
Signs of secondary infection
Fluid balance
Respiratory response (FiO2 requirement, P/F ratio)

Reference: BNFc; BNF 90; RECOVERY trial (Horby et al. NEJM 2021); DEXA-ARDS trial (Villar et al. 2020); NICE NG240 (Meningitis); WHO COVID-19 Therapeutics Guidelines 2023. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

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