Perioperative Corticosteroid - Multiple Doses

We reviewed three high quality studies that compared multiple doses of intravenous dexamethasone to a single dose of dexamethasone.[6,9,12] Due to heterogeneity in the dosage, number of doses, frequency, and duration of treatment, no meta-analyses were performed. 

Xu et al. compared 3 doses (20 mg intraoperatively, and 10 mg on postoperative day 1 and 2) to a single dose (20 mg dose intraoperatively).[6] Wu et al. compared two doses (10 mg intraoperatively and 10 mg 6 hours postoperatively) to a single dose of 10 mg intraoperatively.[12] Backes et al. also compared two doses of dexamethasone (10 mg prior to induction and 10 mg on postoperative day 1) with a single 10 mg dose before induction.[9] All three studies reported decreased opioid consumption and pain in the early postoperative period compared to a single dose.[6,9,12] Two of the three studies reported decreased nausea at 24 hours postoperatively with multiple doses while Xu et al. found no difference between multiple and single doses.

Since a multiple-dose regimen of dexamethasone provides improved reduction in pain, opioid consumption, and nausea compared to a single dose, the workgroup evaluated the number of additional doses needed for improved effect. One high quality study by Lei et al. compared two doses of intravenous dexamethasone (10 mg at induction and at 4 hours postoperatively) to three doses (10 mg at induction, 4 hours postoperatively and 24 hours postoperatively).[8] The authors found that patients who received three doses had decreased pain, opioid consumption, and nausea at 48 hours postoperatively compared to patients who received two doses.[8] Given there is only one study that compares multiple doses, the workgroup does not feel that there is enough evidence to make a definitive recommendation regarding the number of doses (e.g. two, three or more) that should be given  postoperatively. However, the evidence does support that multiple doses of intravenous dexamethasone can help further reduce postoperative pain, opioid consumption, and nausea after primary TJA compared to a single dose.