A. Intravenous or intramuscular administration

When oral therapy is not feasible and the strength, dosage form, and route of administration of the drug reasonably lend the preparation to the treatment of the condition, those products labeled for intravenous or intramuscular use are indicated as follows:

1. Endocrine Disorders
   
   Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy, mineralocorticoid supplementation is of particular importance).
   
   Acute adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; mineralocorticoid supplementation may be necessary, particularly when synthetic analogs are used).
   
   Preoperatively, and in the event of serious trauma or illness, in patients with known adrenal insufficiency or when adrenocortical reserve is doubtful.
   
   Shock unresponsive to conventional therapy if adrenocortical insufficiency exists or is suspected.
   
   Congenital adrenal hyperplasia
   
   Nonsuppurative thyroiditis
   
   Hypercalcemia associated with cancer
2. Rheumatic Disorders
   
   As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in:
   
   Post-traumatic osteoarthritis
   
   Synovitis of osteoarthritis
   
   Rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy).
   
   Acute and subacute bursitis
   
   Epicondylitis
   
   Acute nonspecific tenosynovitis
   
   Acute gouty arthritis
   
   Psoriatic arthritis
   
   Ankylosing spondylitis
3. Collagen Diseases
   
   During an exacerbation or as maintenance therapy in selected cases of:
   
   Systemic lupus erythematosus
   
   Acute rheumatic carditis
4. Dermatologic Diseases
   
   Pemphigus
   
   Severe erythema multiforme (Stevens-Johnson syndrome)
   
   Exfoliative dermatitis
   
   Bullous dermatitis herpetiformis
   
   Severe seborrheic dermatitis
   
   Severe psoriasis
   
   Mycosis fungoides
5. Allergic States
   
   Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in:
   
   Bronchial asthma
   
   Contact dermatitis
   
   Atopic dermatitis
   
   Serum sickness
   
   Seasonal or perennial allergic rhinitis
   
   Drug hypersensitivity reactions
   
   Urticarial transfusion reactions
   
   Acute noninfectious laryngeal edema (epinephrine is the drug of first choice).
6. Ophthalmic Diseases
   
   Severe acute and chronic allergic and inflammatory processes involving the eye, such as:
   
   Herpes zoster ophthalmicus
   
   Iritis, iridocyclitis
   
   Chorioretinitis
   
   Diffuse posterior uveitis and choroiditis
   
   Optic neuritis
   
   Sympathetic ophthalmia
   
   Anterior segment inflammation
   
   Allergic conjunctivitis
   
   Allergic corneal marginal ulcers
   
   Keratitis
7. Gastrointestinal Diseases
   
   To tide the patient over a critical period of the disease in:
   
   Ulcerative colitis (systemic therapy)
   
   Regional enteritis (systemic therapy)
8. Respiratory Diseases
   
   Symptomatic sarcoidosis
   
   Berylliosis
   
   Fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate anti-tuberculosis chemotherapy.
   
   Loeffler's syndrome not manageable by other means.
   
   Aspiration pneumonitis
9. Hematologic Disorders
   
   Acquired (autoimmune) hemolytic anemia.
   
   Idiopathic thrombocytopenic purpura in adults (IV only; IM administration is contraindicated).
   
   Secondary thrombocytopenia in adults
   
   Erythroblastopenia (RBC anemia)
   
   Congenital (erythroid) hypoplastic anemia
10. Neoplastic Diseases
    
    For palliative management of:
    
    Leukemias and lymphomas in adults
    
    Acute leukemia of childhood
11. Edematous States
    
    To induce diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus.
12. Nervous System
    
    Acute exacerbations of multiple sclerosis
13. Miscellaneous
    
    Tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate anti-tuberculosis chemotherapy.
    
    Trichinosis with neurologic or myocardial involvement.
    
    Diagnostic testing of adrenocortical hyperfunction.
    
    Cerebral edema of diverse etiologies in conjunction with adequate neurological evaluation and management.

B. Intra-articular or soft tissue administration

When the strength and dosage form of the drug lend the preparation to the treatment of the condition, those products labeled for intra-articular or soft tissue administration are indicated as adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in:

 

Synovitis of osteoarthritis.

 

Rheumatoid arthritis.

 

Acute and subacute bursitis.

 

Acute gouty arthritis.

 

Epicondylitis.

 

Acute nonspecific tenosynovitis.

 

Post-traumatic osteoarthritis.

C. Intralesional administration

When the strength and dosage form of the drug lend the preparation to the treatment of the condition, those products labeled for intralesional administration are indicated for:

 

Keloids.

 

Localized hypertrophic, infiltrated, inflammatory lesions of: lichen planus, psoriatic plaques, granuloma annulare, and lichen simplex chronicus (neurodermatitis).

 

Discoid lupus erythematosus.

 

Necrobiosis lipoidica diabeticorum.

 

Alopecia areata.

 

They also may be useful in cystic tumors of an aponeurosis tendon (ganglia).

Serious Neurologic Adverse Reactions with Epidural Administration

Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.

In patients on corticosteroid therapy subject to any unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated. Corticosteroids may mask some signs of infection, and new infections may appear during their use. There may be decreased resistance and inability to localize infection when corticosteroids are used.

Prolonged use of corticosteroids may produce posterior subcapsular cataracts, glaucoma with possible damage to the optic nerves, and may enhance the establishment of secondary ocular infections due to fungi or viruses.

Children who are on immunosuppressant drugs are more susceptible to infections than healthy children. Chickenpox and measles, for example, can have a more serious or even fatal course in children on immunosuppressant corticosteroids. In such children or in adults who have not had these diseases, particular care should be taken to avoid exposure. If exposed, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If chickenpox develops, treatment with antiviral agents may be considered.

Similarly, corticosteroids should be used with great care in patients with known or suspected Strongyloides (threadworm) infestation. In such patients, corticosteroid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia.

Usage in Pregnancy

Since adequate human reproduction studies have not been done with corticosteroids, use of these drugs in pregnancy, nursing mothers or women of childbearing potential requires that the possible benefits of the drug be weighed against the potential hazards to the mother and embryo or fetus. Infants born of mothers who have received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism.

Average and large doses of cortisone or hydrocortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium. These effects are less likely to occur with the synthetic derivatives except when used in large doses. Patients with a stressed myocardium should be observed carefully and the drug administered slowly since premature ventricular contractions may occur with rapid administration. Dietary salt restriction and potassium supplementation may be necessary. All corticosteroids increase calcium excretion.

While on corticosteroid therapy patients should not be vaccinated against smallpox. Other immunization procedures should not be undertaken in patients who are on corticosteroids, especially in high doses, because of possible hazards of neurological complications and lack of antibody response.

The use of dexamethasone sodium phosphate injection in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis in which the corticosteroid is used for the management of the disease in conjunction with an appropriate anti-tuberculosis regimen.

If corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity, close observation is necessary as reactivation of the disease may occur. During prolonged corticosteroid therapy, these patients should receive chemoprophylaxis.

Because rare instances of anaphylactoid reactions have occurred in patients receiving parenteral corticosteroid therapy, appropriate precautionary measures should be taken prior to administration, especially when the patient has a history of allergy to any drug.

A. Intravenous or Intramuscular Administration

The initial dosage of dexamethasone sodium phosphate injection may vary from 0.50 mg/day to 9.0 mg/day depending on the specific disease entity being treated. In situations of less severity, lower doses will generally suffice, while in selected patients higher initial doses may be required. Usually the parenteral dosage ranges are one-third to one-half the oral dose given every 12 hours. However, in certain overwhelming, acute, life-threatening situations, administration of dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages.

For the treatment of unresponsive shock high pharmacologic doses of this product are currently recommended. Reported regimens range from 1 to 6 mg/kg of body weight as a single intravenous injection to 40 mg initially followed by repeat intravenous injection every 2 to 6 hours while shock persists.

For the treatment of cerebral edema in adults an initial intravenous dose of 10 mg is recommended followed by 4 mg intramuscularly every six hours until maximum response has been noted. This regimen may be continued for several days postoperatively in patients requiring brain surgery. Oral dexamethasone, 1 to 3 mg t.i.d., should be given as soon as possible and dosage tapered off over a period of five to seven days. Nonoperative cases may require continuous therapy to remain free of symptoms of increased intracranial pressure. The smallest effective dose should be used in children, preferably orally. This may approximate 0.2 mg/kg/24 hours in divided doses.

In treatment of acute exacerbations of multiple sclerosis daily doses of 200 mg of prednisolone for a week followed by 80 mg every other day or 4–8 mg dexamethasone every other day for 1 month have been shown to be effective.

The initial dosage should be maintained or adjusted until a satisfactory response is noted. If after a reasonable period of time there is a lack of satisfactory clinical response, dexamethasone sodium phosphate injection should be discontinued and the patient transferred to other appropriate therapy. It should be emphasized that dosage requirements are variable and must be individualized on the basis of the disease under treatment and the response of the patient.

After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small decrements at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached. It should be kept in mind that constant monitoring is needed in regard to drug dosage. Included in the situations which may make dosage adjustments necessary are changes in clinical status secondary to remissions or exacerbations in the disease process, the patient's individual drug responsiveness and the effect of patient exposure to stressful situations not directly related to the disease entity under treatment. In this later situation it may be necessary to increase the dosage of dexamethasone sodium phosphate injection for a period of time consistent with the patient's condition. If after a long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly.

B. Intra-articular, soft tissue or intralesional administration.

The dose for intrasynovial administration is usually 2 to 4 mg for large joints and 0.8 to 1 mg for small joints. For soft tissue and bursal injections a dose of 2 to 4 mg is recommended. Ganglia require a dose of 1 to 2 mg. A dose of 0.4 to 1 mg is used for injection into tendon sheaths. Injection into intervertebral joints should not be attempted at any time and hip joint injection cannot be recommended as an office procedure.

Intrasynovial and soft tissue injections should be employed only when affected areas are limited to 1 or 2 sites. It should be remembered that corticoids provide palliation only and that other conventional or curative methods of therapy should be employed when indicated.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Frequency of injection usually ranges from once every 3 to 5 days to once every 2 to 3 weeks. Frequent intra-articular injection may cause damage to joint tissue.

Storage

Store at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Sensitive to heat. Do not autoclave.

Protect from freezing.

Protect from light.

Single dose vials–Store in container until time of use. Discard unused portion.

Multiple dose vials–Store in container until contents are used.

Lake Zurich, IL 60047

www.fresenius-kabi.com/us

45955F

Revised: July 2020