Should statins (HMG-CoA reductase inhibitors) be continued in a patient with dengue fever?

Should Statins Be Continued in Patients with Dengue Fever?

Yes, statins should be continued in patients with dengue fever who are already taking them for cardiovascular indications, as discontinuation poses significant cardiovascular risks that outweigh any theoretical concerns in dengue.

Primary Evidence Supporting Continuation

The most definitive evidence comes from a randomized controlled trial specifically evaluating statin safety in dengue patients. A double-blind, placebo-controlled trial of 300 Vietnamese adults with acute dengue found that lovastatin (80 mg daily for 5 days) was safe and well tolerated, with adverse events occurring at similar rates in both treatment and placebo groups (55% vs 64%, p=0.13). 1 This trial explicitly concluded that "continuing established statin therapy in patients who develop dengue is safe." 1

Critical Cardiovascular Risk of Statin Discontinuation

The cardiovascular guidelines provide compelling evidence against stopping statins:

• Statin withdrawal increases 1-year mortality with a hazard ratio of 2.7 in patients with cardiovascular disease 2
• Discontinuing statins during hospitalization increases short-term mortality and major adverse cardiac events 2
• The ACC/AHA explicitly states that perioperative or in-hospital statin discontinuation is a Class III (Harm) recommendation 2

Dengue-Specific Cardiovascular Considerations

Dengue itself significantly increases acute cardiovascular risk. A large population-based study demonstrated that the incidence rate ratio for major adverse cardiovascular events (MACE) was 17.9 (95% CI 15.80-20.37) during the first week after dengue diagnosis, with elevated risks for AMI (IRR 13.53), heart failure (IRR 27.24), and stroke (IRR 15.56) 3. This heightened cardiovascular vulnerability makes statin continuation even more critical in patients with pre-existing cardiovascular disease.

Evidence Against Therapeutic Benefit but Supporting Safety

While statins do not appear to improve dengue outcomes:

• The lovastatin trial found no beneficial effect on clinical manifestations, disease progression, fever clearance, or viremia 1
• A retrospective cohort study of 257 dengue patients with hyperlipidemia in Singapore found statin use had minimal effect on dengue severity (adjusted RR for DHF/DSS = 0.66,95% CI 0.41-1.08) 4

However, the absence of therapeutic benefit does not justify discontinuation in patients with established cardiovascular indications, as the safety profile remains favorable. 1

Clinical Algorithm for Decision-Making

For patients already on statins who develop dengue:

1. Continue the statin at the current dose 1
2. Monitor for typical dengue complications (thrombocytopenia, hemorrhage, shock) as you would in any dengue patient 1
3. Do not attribute common dengue manifestations (fever, myalgia, thrombocytopenia) to statin adverse effects 1

For patients not on statins who develop dengue:

• Do not initiate statins for dengue treatment, as there is no evidence of therapeutic benefit 1, 4

Important Caveats

• The safety data specifically addresses continuation of established therapy, not initiation during acute dengue 1
• Severe dengue with hepatic dysfunction may warrant temporary dose reduction or monitoring, though this was not specifically addressed in the trial 1
• The cardiovascular risks of statin discontinuation (mortality HR 2.7) far exceed any theoretical concerns about bleeding risk in dengue 2, 3

Comparison with Antiplatelet Therapy

Unlike statins, antiplatelet therapy presents a more nuanced decision. A retrospective study found that both continuation and discontinuation of antiplatelet therapy in dengue with thrombocytopenia were largely safe based on clinical judgment, with no significant difference in major adverse cardiac and cerebrovascular events or bleeding complications 5. However, statins have a clearer safety profile and stronger evidence supporting continuation. 1