Dexamethasone vs. prednisone in pediatric acute lymphoblastic leukemia

With contemporary multi-agent chemotherapy regimens, nearly 90% of children with acute lymphoblastic leukemia (ALL) can be cured (1,2). Glucocorticoids have remained an essential part of the induction chemotherapy regimen in childhood ALL for decades (3). Both prednisone (PDN) and dexamethasone (DXM) are glucocorticoids used in induction therapy, with different anti-leukemic efficacy, central nervous system (CNS) penetration, and toxicity profiles. In general, DXM contains more potent cytotoxic glucocorticoids with better CNS penetration, which is particularly appealing to T-cell ALL with higher rates of CNS disease (4-7). However, the benefits of DXM have been offset by the higher incidence of fatal infection in induction, and more treatment-related toxicity such as avascular necrosis (AVN) (8,9). Despite previous attempts to directly compare the effects of two glucocorticoids during induction by several randomized clinical trials, no consensus has been reached regarding the optimal glucocorticoid in induction, at which dose, and the duration of therapy (8,10-12).