What is the role of steroids, such as methylprednisolone (corticosteroids), in the management of dengue hemorrhagic fever?

Role of Steroids in Dengue Hemorrhagic Fever

Corticosteroids are not recommended for routine use in the management of dengue hemorrhagic fever as there is insufficient evidence supporting their benefit for reducing mortality or preventing complications. 1, 2

Evidence Assessment

Current Evidence Against Routine Use

• Multiple systematic reviews have evaluated corticosteroid use in dengue hemorrhagic fever and dengue shock syndrome:
  • A Cochrane review analyzing four trials with 284 participants found that corticosteroids were no more effective than placebo or no treatment in reducing deaths (RR 0.68,95% CI 0.42 to 1.11) 2
  • The same review showed no benefit for reducing the need for blood transfusion (RR 1.08,95% CI 0.52 to 2.24) or serious complications such as convulsions and pulmonary hemorrhage 2
  • Another systematic review confirmed that methylprednisolone, hydrocortisone, and other corticosteroids did not reduce mortality in children with hemorrhagic dengue 3

Potential Risks

• Corticosteroids can potentially cause harm through:
  • Secondary adrenal insufficiency 4
  • Altered immune response that may affect viral clearance 4
  • Increased risk of secondary infections 4
  • Other adverse effects including hyperglycemia, which is particularly concerning in dengue patients who may already have metabolic derangements 4

Management Recommendations

Primary Treatment Approach

• The mainstay of treatment for dengue hemorrhagic fever remains:
  • Supportive care
  • Aggressive fluid management, particularly if hypotension develops
  • Close monitoring of vital signs and hematological parameters
  • Judicious administration of blood products when indicated

Specific Scenarios Where Steroids Might Be Considered

While routine use is not recommended, there are limited scenarios where corticosteroids might be considered:

1. Dengue-associated hemophagocytic lymphohistiocytosis (HLH):

   • Some case reports suggest potential benefit of steroids in this rare complication
   • However, even this complication may resolve with steroid-sparing supportive care 5

2. Rescue therapy for refractory shock:

   • Non-randomized trials have suggested possible benefit when used as rescue medication for severe shock that is unresponsive to standard measures 6
   • However, this evidence is limited and of low quality

Important Caveats

• The evidence base for corticosteroid use in dengue is small, with most studies being older (>20 years) and having methodological limitations 1
• The quality of evidence is generally low to very low 1
• There is insufficient evidence to evaluate the effects of corticosteroids in dengue outside the context of a randomized controlled trial 1

Conclusion

Based on current evidence, corticosteroids should not be routinely used in the management of dengue hemorrhagic fever. The focus should remain on early recognition, careful monitoring, and appropriate fluid management. Any consideration of corticosteroid use should ideally be within the context of a clinical trial.