Corticosteroids

Dexamethasone

The recommended adult dose schedule is:

*Course generally 10 days but this can be shortened if the patient has made a full recovery prior to that, or if the risk of side effects by that point significantly outweighs benefit.

Oral administration should be used first line where possible. IV administration should be limited to patients with no alternative route of administration. Treatment should stop if discharged from hospital within the 10 days.

Hydrocortisone

The recommended adult dose schedule is:

• 50mg hydrocortisone administered intravenously three times per day for 7-10 days
• A longer low dose duration can be considered for patients with septic shock

Please note that the majority of evidence in the published meta-analysis emanates from the assessment of dexamethasone in the RECOVERY trial.

For information on use in pregnant or breastfeeding women, please refer to the Summary of Product Characteristics (SPC) for dexamethasone and hydrocortisone (https://www.medicines.org.uk/emc/product/9377/smpc#gref) pregnant women with COVID-19 should be discussed with a senior obstetrician.

Dexamethasone crosses the placenta and repeated courses of maternal dexamethasone have been linked with developmental delay in children. Guidance by the Royal College of Obstetricians and Gynaecologists suggests 40mg oral prednisolone (instead of dexamethasone). Where the oral route is not available intravenous hydrocortisone 80 mg twice daily can be used. Where the mother has had two doses IM dexamethasone for foetal lung maturation start prednisolone after completion of dexamethasone if still appropriate.

Adverse effects include gastrointestinal discomfort, dyspepsia, peptic ulceration, sleep disturbances, nausea and anxiety. Please refer to the BNF for further details.

Gastrointestinal

Advise patients to take oral dexamethasone with or after food. When prescribing dexamethasone, consider the patient’s risk factors for gastrointestinal ulceration. A proton pump inhibitor should be strongly considered for high-risk patients for the duration of the course but should be discontinued once dexamethasone has stopped.

Diabetes

High Blood Glucose levels with COVID-19 infection have been shown to result in worse patient outcomes. All patients who have diabetes or who are persistently hyperglycaemic should be discussed with the diabetes team.

• Glucose monitoring frequency (Target glucose 6.0-10.0mmol/L; up to 12.0mmol/L is acceptable)
  • People not known to have diabetes
    • Check the glucose 4 times daily (before meals and at bedtime). If after 48 hours all glucose results are <10.0 mmol/L reduce frequency to once daily at 17.00-18.00 hrs. Continue until dexamethasone is stopped.
    • If any fasting glucose is above 10.0 mmol/L continue 4 times daily monitoring and discuss with the diabetes team.
  • People with diabetes
    • Throughout the admission, check fasting glucose at least 6 hourly, or more frequently if the glucose is outside the 6.0 -10.0 mmol/L range. Inform the diabetes team of admission.

• National guidance is available at: https://www.diabetes.org.uk/professionals/resources/coronavirus-clinical-guidance#inpatient-guidance

Frailty/elderly

Use with caution in the elderly; in addition to common side-effects consider increased risk of delirium, agitation, falls and fluid retention. If patients are already on maintenance steroids (acute/maintenance) discuss with local endocrinology team. Duration of dexamethasone may require review if side-effects in the elderly are significant.

Sleep disorders

Dexamethasone should be given in the morning to minimise sleep disruption.

All adverse drug reactions for patients receiving dexamethasone for COVID-19 must be reported to the using MHRA using COVID-19 Yellow Card reporting site.

Please refer to the BNF or Summary of product characteristics for a list of potential drug interactions.

For drug interactions please also see the COVID-19 drug interaction checker: https://www.covid19-druginteractions.org/