While I generally agree with the adage, "If it ain’t broke, don’t fix it,"  I also feel that dexamethasone is often given an unfair "bum rap." 

 

It has been four years since my son was diagnosed with CAH.  In that time, he has been on dex for about three years.  And on hydrocortisone for a total of about one.  So we have experience with both medications. 

 

My feeling is that either one can work...if used properly.  And either one can give you problems....if used improperly. 

 

As for one being more "circadian" friendly than the other...again, I think it depends on the drug you use, and when you give it, since each has different biochemical properties.  

 

Personally, I think a single dose of dex, given in the morning, is very circadian friendly.  In my opinion....if you drew a curve that charted the action of a dose of dex in the bloodstream (given in the morning), and compared it to a curve that depicted the natural circadian secretion of cortisol, you would find the two shapes to be surprisingly similar.