Dexamethasone

Dexamethasone is a potent synthetic member of the glucocorticoid class of steroid drugs that has anti-inflammatory and immunosuppressant effects. It is 25 times more potent than cortisol in its glucocorticoid effect, while having minimal mineralocorticoid effect.

Anti-inflammatory
Dexamethasone is used to treat many inflammatory and autoimmune conditions, such as rheumatoid arthritis and bronchospasm. Idiopathic thrombocytopenic purpura, decreased numbers of platelets due to an immune problem, responds to 40 mg daily for four days; it may be administered in 14-day cycles. It is unclear whether dexamethasone in this condition is significantly better than other glucocorticoids.

It is also given in small amounts before and/or after some forms of dental surgery, such as the extraction of the wisdom teeth, an operation which often leaves the patient with puffy, swollen cheeks.

It is injected into the heel when treating plantar fasciitis, sometimes in conjunction with triamcinolone acetonide.

It is useful to counteract allergic anaphylactic shock, if given in high doses.

It is present in certain eye drops – particularly after eye surgery– and as a nasal spray (trade name Dexacort), and certain ear drops (Sofradex, when combined with an antibiotic and an antifungal).

Dexamethasone is used in transvenous screw-in cardiac pacing leads to minimize the inflammatory response of the myocardium. The steroid is released into the myocardium as soon as the screw is extended and can play a significant role in minimizing the acute pacing threshold due to the reduction of inflammatory response. The typical quantity present in a lead tip is less than 1.0 mg.

Dexamethasone is often administered before antibiotics in cases of bacterial meningitis. It then acts to reduce the inflammatory response of the body to the bacteria killed by the antibiotics (bacterial death releases proinflammatory mediators that can cause a response which is harmful to the patient), thus improving prognosis and outcome.



Oncologic uses
Cancer patients undergoing chemotherapy are given dexamethasone to counteract certain side effects of their antitumor treatment. Dexamethasone can augment the antiemetic effect of 5-HT3 receptor antagonists, such as ondansetron.

In brain tumors (primary or metastatic), dexamethasone is used to counteract the development of edema, which could eventually compress other brain structures. It is also given in cord compression, where a tumor is compressing the spinal cord.

Dexamethasone is also used as a direct chemotherapeutic agent in certain hematological malignancies, especially in the treatment of multiple myeloma, in which dexamethasone is given alone or in combination with other chemotherapeutic drugs, including most commonly with thalidomide (thal-dex), lenalidomide, bortezomib (Velcade; Vel-dex), or a combination of Adriamycin (doxorubicin) and vincristine (VAD) or VRD- Velcade, Revlimid and Dexamethasone.

Endocrine
Dexamethasone is the treatment for the very rare disorder of glucocorticoid resistance.

In adrenal insufficiency and Addison's disease, dexamethasone is prescribed when the patient does not respond well to prednisone or methylprednisolone.

Obstetrics
Dexamethasone may be given to women at risk of delivering prematurely to promote maturation of the fetus' lungs. This has been associated with low birth weight, although not with increased rates of neonatal death.

High altitude illnesses
Dexamethasone is used in the treatment of high altitude cerebral edema, as well as pulmonary edema. It is commonly carried on mountain climbing expeditions to help climbers deal with altitude sickness.

Congenital adrenal hyperplasia
Dexamethasone has been used as an off-label prenatal treatment for the symptoms of congenital adrenal hyperplasia (CAH) in female fetuses. CAH causes a variety of physical abnormalities, notably ambiguous genitalia in girls. Early prenatal CAH treatment has been shown to reduce some CAH symptoms, but it does not treat the underlying congenital disorder.

A small clinical trial found long-term effects on verbal working memory among the small group of children treated prenatally, but the small number of test subjects means the study cannot be considered definitive. Administration of prenatal dexamethasone has been the subject of controversy over issues of informed consent and because treatment must predate a clinical diagnosis of CAH in the female fetus.

A study utilizing Freedom of Information Act findings to "detail an extremely troubling off-label medical intervention employed in the U.S. on pregnant women to intentionally engineer the development of their fetuses for sex normalization purposes." Glucocorticoids may alter “fetal programming,” potentially resulting in serious metabolic problems that will not become apparent until adulthood. Prenatal treatment of female fetuses could prevent those fetuses from becoming lesbians after birth, may make them more likely to engage in "traditionally" female-identified behaviour and careers, and more interested in bearing and raising children. The essay suggests prenatal "dex" treatments constitute the first known attempt to use an in utero method to attempt to reduce the incidence of homosexuality in humans. A medical consensus in 2010 by the Endocrine Society and affiliated organizations indicated prenatal dexamethasone for CAH should be regarded as experimental and should only be used in Institutional Review Board-approved controlled clinical trials at centers large enough to collect meaningful data.

Abuses
Dexamethasone has also been used in the hope of enhancing sports performance.

Long term use of dexamethasone under the brand name Oradexo.

Since dexamethasone is a CYP2D6 enzyme inducer, it can increase the effects of many prodrugs and protoxins which are metabolized via CYP2D6 (ex. tramadol, codeine) by directly increasing the amount of the active metabolite produced.

Diagnostic use
Dexamethasone is also used in a diagnostic context, namely in its property to suppress the natural pituitary-adrenal axis.

Patients presenting with clinical signs of glucocorticoid excess (Cushing's syndrome) are generally diagnosed by a 24-hour urine collection for cortisol or by a dexamethasone suppression test. During the latter, the response of the body to a high dose of glucocorticoids is monitored. Various forms are performed. In the most common form, a patient takes a nighttime dose of either 1 or 4 mg of dexamethasone, and the serum cortisol levels are measured in the morning. If the levels are relatively high (over 5 µg/dL or 150 nmol/L), then the test is positive and the patient has an autonomous source of either cortisol or ACTH, indicating Cushing's syndrome where the tumor does not have a feedback mechanism. If ACTH levels are lowered by at least 50%, this would indicate Cushing's disease, since the pituitary adenoma has a feedback mechanism that has been reset to a higher level of cortisol. Longer versions rely on urine collections on oral dexamethasone over various days.

Veterinary use
Combined with marbofloxacin and clotrimazole, dexamethasone is available under the name Aurizon, CAS number 115550-35-1, and used to treat difficult ear infections, especially in dogs. It can also be combined with trichlormethiazide to treat horses with swelling of distal limbs and general bruising.

Contraindications
Some of these contraindications are relative:
 * Existing gastrointestinal ulceration
 * Cushing's syndrome
 * Severe forms of heart insufficiency
 * Severe hypertension
 * Uncontrolled diabetes mellitus
 * Systemic tuberculosis
 * Severe systemic bacterial, and fungal infections
 * Pre-existing wide angle glaucoma
 * Osteoporosis

Side effects
If dexamethasone is given orally or by injection (parenteral) over a period of more than a few days, side effects common to systemic glucocorticoids may occur. These may include:
 * Stomach upset, increased sensitivity to stomach acid to the point of ulceration of esophagus, stomach, and duodenum
 * Increased appetite leading to significant weight gain
 * A latent diabetes mellitus often becomes manifest, glucose intolerance is worsened in patients with pre-existing diabetes
 * Immunosuppressant action, particularly if given with other immunosuppressants, such as cyclosporine, may allow bacterial, viral, and fungal disease to progress more easily and can become life-threatening; fever as a warning symptom is often suppressed.
 * Psychiatric disturbances, including personality changes, irritability, euphoria, or mania and mood swings.
 * Osteoporosis under long term treatment, pathologic fractures (e.g., hip)
 * Muscle atrophy, negative protein balance (catabolism)
 * Elevated liver enzymes, fatty liver degeneration (usually reversible)
 * Cushingoid (syndrome resembling hyperactive adrenal cortex with increase in adiposity, hypertension, bone demineralization, etc.)
 * Depression of the adrenal gland is usually seen, if more than 1.5 mg daily are given for more than three weeks to a month.
 * Hypertension, fluid and sodium retention, edema, worsening of heart insufficiency (due to mineralocorticoid activity)
 * Dependence with withdrawal syndrome is frequently seen.
 * Increased intraocular pressure, certain types of glaucoma, cataract (serious clouding of eye lenses)
 * 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.
 * Pronounced night sweats.
 * Allergic reactions (though infrequently): Anaphylactoid reaction, anaphylaxis, angioedema.

Other side effects have been noted, and should cause concern if they are more than mild.

The short-time treatment for allergic reaction, shock, and diagnostic purposes usually does not cause serious side effects.

Novelist Michael Cox believed his first book, The Meaning of Night was a side effect of prescription dexamethasone, giving him both "formidable energy" while quelling his creative doubts.

Interactions

 * NSAIDs and alcohol: increased risk of gastrointestinal ulceration
 * Mineralocorticoids: increased risk of hypertension, edema and heart problems
 * Oral antidiabetic drugs and insulin: antidiabetic therapy may have to be adjusted
 * Tramadol: increased conversion to O-desmethyltramadol
 * Codeine: increased conversion to morphine

Other interactions (with certain antibiotics, estrogens, ephedrine, digoxin) are known.

Synthesis
To synthesize dexamethasone, 16β-methylprednisolone acetate is dehydrated to the 9,11-dehydro derivative. This is then reacted with a source of hypobromite, such as basic N-bromosuccinimide, to form the 9α-bromo-11β-hydrin derivative, which is then ring-closed to an epoxide. A ring-opening reaction with hydrogen fluoride in tetrahydrofuran gives dexamethasone.


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