This study by Wei and colleagues demonstrates a clear short-term advantage for high-dose dexamethasone over prednisone. High-dose dexamethasone resulted in a superior overall response rate, superior time to response, and fewer corticosteroid-associated adverse effects comparted to prednisone. In the longer term, dexamethasone and prednisone were equivalent in terms of sustained response and sustained complete response rates.

There are several limitations that warrant mentioning. The exclusion criteria were extensive, potentially limiting generalizability. In total, 28/95 (29.5%) patients in the high-dose dexamethasone arm received a second 4-day course. Half of these patients responded, and the authors note that the additional course of therapy significantly increased the overall response rate in this arm (P=0.029). The high frequency of a second course of high-dose dexamethasone reduces the difference in corticosteroid exposure between the two arms.

The most appropriate take-home message from this study may be that two courses of high-dose dexamethasone are superior to prednisone taper.

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