Use of Dexamethasone in Patients with High-Grade Glioma: A Clinical Practice Guideline

Background: Dexamethasone is the corticosteroid most commonly used for the management of vasogenic edema and increased intracranial pressure in patients with brain tumours. It is also used after surgery (before embarking on radiotherapy), particularly in patients whose tumours exert significant mass effect. Few prospective clinical trials have set out to determine the optimal dose and schedule for dexamethasone in patients with primary brain tumours, and subsequently, fewer clinical practice guideline recommendations have been formulated. Method: A review of the scientific literature published to November 2012 considered all publications that addressed dexamethasone use in adult patients with brain tumours. Evidence was selected and reviewed by a working group comprising 3 clinicians and 1 methodologist. The resulting draft guideline underwent internal review by members of the Alberta Provincial cns Tumour Team, and feedback was incorporated into the final version of the guideline. Recommendations: Based on the evidence available to date, the Alberta Provincial cns Tumour Team makes these recommendations: Treatment with dexamethasone is recommended for symptom relief in adult patients with primary high-grade glioma and cerebral edema. After surgery, a maximum dose of 16 mg daily, administered in 4 equal doses, is recommended for symptomatic patients. This protocol should ideally be started by the neurosurgeon. A rapid dexamethasone tapering schedule should be considered where appropriate. Patients who have high-grade tumours, are symptomatic, or have poor life expectancy, can be maintained on a 0.5–1.0 mg dose of dexamethasone daily. Side effects with dexamethasone are common, and they increase in frequency and severity with increased dose and duration of therapy. Patients should be carefully monitored for endocrine, muscular, skeletal, gastrointestinal, psychiatric, and hematologic complications, and for infections and other general side effects.