Side Effects of Decadron (dexamethasone)

Decadron (dexamethasone) is a synthetic (man-made) corticosteroid. 

Corticosteroids are naturally-occurring chemicals produced by the adrenal glands located above the kidneys. Corticosteroids affect the function of many cells within the body and suppress the immune system. Corticosteroids also block inflammation and are used in a wide variety of inflammatory diseases affecting many organs. 

Dexamethasone is used to reduce inflammation in many conditions such as rheumatoid arthritis, systemic lupus, acute gouty arthritis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. 

• Dexamethasone is also used to treat severe allergic conditions that fail to respond to other treatments, chronic skin conditions, and chronic allergic and inflammatory conditions of the uvea, iris, conjunctiva, and optic nerves of the eyes.
• Dexamethasone is used in the treatment of cancers of the white blood cells (leukemias), and lymph gland cancers (lymphomas), and blood diseases involving destruction by the body's own immune system of platelets are also treated with dexamethasone.
• Dexamethasone is also used to treat thyroiditis and sarcoidosis and is used as replacement therapy in patients whose adrenal glands are unable to produce sufficient amounts of corticosteroids.
• Dexamethasone is also used to treat COVID-19 patients with symptoms severe enough to need oxygen.
• Many of the medical problems treated by this drug are “off label”; that is, its use is not sanctioned or approved by the FDA. The brand name Decadron is discontinued in the U.S.

Common side effects of Decadron include

• fluid retention,
• weight gain,
• high blood pressure,
• loss of potassium,
• increase in serum glucose levels (especially in diabetics),
• headache,
• muscle weakness,
• puffiness of and hair growth on the face,
• thinning and easy bruising of the skin,
• glaucoma,
• cataracts,
• peptic ulcers,
• worsening of diabetes,
• irregular menstrual periods,
• growth retardation in children,
• convulsions, and
• psychic disturbances (depression, euphoria, insomnia, mood swings, personality changes, and even psychotic behavior).

Serious side effects of Decadron include

• impaired immune response that can make patients more susceptible to infections and reduce the effectiveness of vaccines,
• impaired calcium absorption and new bone formation that can lead to osteoporosis and an increased risk of bone fractures, and rarely, the destruction of large joints.

Abruptly stopping dexamethasone after prolonged use can cause symptoms of corticosteroid insufficiency, with accompanying

• nausea,
• vomiting, and even
• shock. 

Drug interactions of Decadron include blood thinners because corticosteroids may increase or decrease their effect.

• Phenobarbital, ephedrine, phenytoin, and rifampin may increase the breakdown of corticosteroids by the liver, resulting in lower blood levels and reduced effects.
• Mifepristone may reduce the action of corticosteroids via unknown mechanisms.
• Dexamethasone may decrease blood levels of mifepristone. Mifepristone should not be combined with steroids. 

Use of dexamethasone in pregnant women has not been adequately studied. Dexamethasone has not been adequately evaluated in nursing mothers. Corticosteroids appear in breast milk and may cause side effects in infants. Consult your doctor before breastfeeding.

Side effects of dexamethasone depend on the dose, the duration and the frequency of administration. Short courses of dexamethasone usually are well tolerated with few and mild side effects. Long term, high dose dexamethasone usually will produce predictable and potentially serious side effects.

Whenever possible, the lowest effective dose of dexamethasone should be used for the shortest possible length of time to minimize side effects. Alternate day dosing also can help reduce side effects.

Side effects of dexamethasone and other corticosteroids range from mild annoyances to serious irreversible damage. Side effects include:

• fluid retention,
• weight gain,
• high blood pressure,
• loss of potassium,
• increase in serum glucose levels (especially in diabetics),
• headache,
• muscle weakness,
• puffiness of and hair growth on the face,
• thinning and easy bruising of skin,
• glaucoma,
• cataracts,
• peptic ulceration,
• worsening of diabetes,

Other side effects include:

• irregular menses,
• growth retardation in children,
• convulsions, and
• psychic disturbances.

Psychic disturbances include:

• depression,
• euphoria,
• insomnia,
• mood swings,
• personality changes, and
• even psychotic behavior.

Prolonged use of dexamethasone can depress the ability of body's adrenal glands to produce corticosteroids. Abruptly stopping dexamethasone in these individuals can cause symptoms of corticosteroid insufficiency, with accompanying nausea, vomiting, and even shock.

Therefore, withdrawal of dexamethasone usually is accomplished by gradually reducing the dose. Gradually tapering dexamethasone not only minimizes the symptoms of corticosteroid insufficiency, but also reduces the risk of an abrupt flare of the disease under treatment.

Dexamethasone and other corticosteroids can mask signs of infection and impair the body's natural immune response that is important in fighting infection. Patients on corticosteroids are more susceptible to infections and can develop more serious infections than individuals not receiving corticosteroids. For example, chickenpox and measles viruses can produce serious and even fatal illnesses in patients on high doses of dexamethasone.

Live virus vaccines, such as smallpox vaccine, should be avoided in patients taking high doses of dexamethasone, since even vaccine viruses may cause disease in these patients.

Some infectious diseases, such as tuberculosis (TB) and malaria, can remain dormant in a patient for years. Dexamethasone and other corticosteroids can reactivate dormant infections. Patients with dormant tuberculosis may require treatment of the TB while undergoing corticosteroid treatment.

By interfering with the patient's immune response, dexamethasone can impede the effectiveness of vaccinations. Dexamethasone can also interfere with the tuberculin (TB) skin test and cause falsely negative results in patients with dormant tuberculosis infection.

Dexamethasone impairs calcium absorption and new bone formation. Patients on prolonged treatment with dexamethasone and other corticosteroids can develop osteoporosis and an increased risk of bone fractures. Supplemental calcium and vitamin D are encouraged to slow this process of bone thinning.

It has been demonstrated in some groups of patients treated with steroids that the loss of bone may be prevented by treatment with biphosphonate drugs, for example, alendronate (Fosamax).

In rare individuals, destruction of large joints can occur while undergoing treatment with dexamethasone or other corticosteroids. These patients experience severe pain in the involved joints, and can require joint replacements. The reason behind such destruction is not clear.

The following adverse reactions have been reported with Decadron or other corticosteroids:

Allergic Reactions

• Anaphylactoid reaction, anaphylaxis, angioedema.

Cardiovascular

• Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, fat embolism, hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction, edema, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis.

Dermatologic

• Acne, allergic dermatitis, dry scaly skin, ecchymoses and petechiae, erythema, impaired wound healing, increased sweating, rash, striae, suppression of reactions to skin tests, thin fragile skin, thinning scalp hair, urticaria.

Endocrine

• Decreased carbohydrate and glucose tolerance, development of cushingoid state, hyperglycemia, glycosuria, hirsutism, hypertrichosis, increased requirements for insulin or oral hypoglycemic agents in diabetes, manifestations of latent diabetes mellitus, menstrual irregularities, secondary adrenocortical and pituitary unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness), suppression of growth in pediatric patients.

Fluid And Electrolyte Disturbances

• Congestive heart failure in susceptible patients, fluid retention, hypokalemic alkalosis, potassium loss, sodium retention, tumor lysis syndrome.

Gastrointestinal

• Abdominal distention, elevation in serum liver enzyme levels (usually reversible upon discontinuation), hepatomegaly, increased appetite, nausea, pancreatitis, peptic ulcer with possible perforation and hemorrhage, perforation of the small and large intestine (particularly in patients with inflammatory bowel disease), ulcerative esophagitis.

Metabolic

• Negative nitrogen balance due to protein catabolism.

Musculoskeletal

• Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle 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.

Other

• Abnormal fat deposits, decreased resistance to infection, hiccups, increased or decreased motility and number of spermatozoa, malaise, moon face, weight gain.

Aminoglutethimide

• Aminoglutethimide may diminish adrenal suppression by corticosteroids.

Amphotericin B Injection And Potassium-Depleting Agents

• When corticosteroids are administered concomitantly with potassium-depleting agents (e.g., amphotericin B, diuretics), patients should be observed closely for development of hypokalemia.
• In addition, there have been cases reported in which concomitant use of amphotericin B and hydrocortisone was followed by cardiac enlargement and congestive heart failure.

Antibiotics

• Macrolide antibiotics have been reported to cause a significant decrease in corticosteroid clearance.

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 hours before initiating corticosteroid therapy.

Anticoagulants, Oral

• Co-administration of corticosteroids and warfarin usually results in inhibition of response to warfarin, although there have been some conflicting reports.
• Therefore, coagulation indices should be monitored frequently to maintain the desired anticoagulant effect.

Antidiabetics

• Because corticosteroids may increase blood glucose concentrations, dosage adjustments of antidiabetic agents may be required.

Antitubercular Drugs

• Serum concentrations of isoniazid may be decreased.

Cholestyramine

• Cholestyramine may increase the clearance of 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.

Dexamethasone Suppression Test (DST)

• False-negative results in the dexamethasone suppression test (DST) in patients being treated with indomethacin have been reported.
• Thus, results of the DST should be interpreted with caution in these patients.

Digitalis Glycosides

• Patients on digitalis glycosides may be at increased risk of arrhythmias due to hypokalemia.

Ephedrine

• Ephedrine may enhance the metabolic clearance of corticosteroids, resulting in decreased blood levels and lessened physiologic activity, thus requiring an increase in corticosteroid dosage.

Estrogens, Including Oral Contraceptives

• Estrogens may decrease the hepatic metabolism of certain corticosteroids, thereby increasing their effect.

Hepatic Enzyme Inducers, Inhibitors And Substrates

• Drugs which induce cytochrome P450 3A4 (CYP 3A4) enzyme activity (e.g., barbiturates, phenytoin, carbamazepine, rifampin) may enhance the metabolism of corticosteroids and require that the dosage of the corticosteroid be increased.
• Drugs which inhibit CYP 3A4 (e.g., ketoconazole, macrolide antibiotics such as erythromycin) have the potential to result in increased plasma concentrations of corticosteroids. Dexamethasone is a moderate inducer of CYP 3A4.
• Co-administration with other drugs that are metabolized by CYP 3A4 (e.g., indinavir, erythromycin) may increase their clearance, resulting in decreased plasma concentration.

Ketoconazole

• Ketoconazole has been reported to decrease the metabolism of certain corticosteroids by up to 60%, leading to increased risk of corticosteroid side effects. In addition, ketoconazole alone can inhibit adrenal corticosteroid synthesis and may cause adrenal insufficiency during corticosteroid withdrawal.

Nonsteroidal Anti-Inflammatory Agents (NSAIDS)

• Concomitant use of aspirin (or other nonsteroidal anti-inflammatory agents) and corticosteroids increases the risk of gastrointestinal side effects.
• Aspirin should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia.
• The clearance of salicylates may be increased with concurrent use of corticosteroids.

Phenytoin

• In post-marketing experience, there have been reports of both increases and decreases in phenytoin levels with dexamethasone co-administration, leading to alterations in seizure control.

Skin Tests

• Corticosteroids may suppress reactions to skin tests.

Thalidomide

• Co-administration with thalidomide should be employed cautiously, as toxic epidermal necrolysis has been reported with concomitant use.

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.
• Routine administration of vaccines or toxoids should be deferred until corticosteroid therapy is discontinued if possible.