Corticosteroids for treating dengue infection in children and adults

Dengue is a disease caused by a virus transmitted by mosquitoes, occurring in many resource-limited countries, and children are often most severely affected. Most infected patients will recover with mild symptoms, but a few progress to severe dengue and may die. There is no specific treatment for dengue, but some clinicians provide corticosteroids at an early stage to prevent progression to severe dengue disease; and some treat patients with dengue-related shock with corticosteroids to improve survival. It is important to summarise the effects of corticosteroids in dengue.

We conducted a search up to 6 January 2014 and included eight studies which enrolled 948 participants in total. Four studies of corticosteroids in the treatment of dengue-related shock assessed if corticosteroids could improve survival, but these studies were small and older than 20 years. The evidence we found is of very low quality and do not provide any reliable evidence for corticosteroids for treating dengue-related shock. Four trials evaluated whether corticosteroids provided at an early stage of dengue could prevent development of complications of severe dengue. These trials were more recent, but data were insufficient to be sure whether corticosteroids have an effect on the course of the disease.

Authors' conclusions: 

The evidence from trials using corticosteroids in dengue is inconclusive and the quality of evidence is low to very low. This applies to both the use of corticosteroids in dengue-related shock and for dengue at an early stage. There is insufficient evidence to evaluate the effects of corticosteroids in the treatment of early stage dengue fever and dengue-related shock outside of the context of a randomized controlled trial.

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Background: 

Dengue is a common and important mosquito-borne viral infection. In many low- and middle-income countries it is endemic and is an important public health problem. Severe dengue is an important cause of death in children. There is no specific treatment for dengue, but observational studies suggest corticosteroids may have a benefit in dengue-related shock, and some people believe corticosteroids may prevent the progression to severe illness if given early in the course of the illness.

Objectives: 

To compare treatment of dengue with and without use of corticosteroids or placebo in relation to preventing shock-related death and disease progression in children and adults.

Search strategy: 

We searched the Cochrane Infectious Disease Group Centralized Register; CENTRAL; MEDLINE; EMBASE; and LILACS, up to 6 January 2014. We screened reference lists and contacted the relevant study authors for additional information where required.

Selection criteria: 

Randomized controlled trials or quasi-randomized controlled trials comparing corticosteroids with placebo or no corticosteroids in patients diagnosed with dengue-related shock, or patients in an early symptomatic state of dengue with positive serology.

Data collection and analysis: 

Two researchers independently screened eligibility of records, extracted data and assessed quality of the studies. We presented findings in meta-analysis and summary of findings tables and evaluated the quality of evidence using GRADE.

Main results: 

We included eight studies enrolling 948 participants in this review.

Paitents with dengue-related shock

Four studies enrolled children younger than 15 years with dengue-related shock at hospitals in Southeast Asia and evaluated intravenous corticosteroids. The trials did not detect an effect on death (four trials, 284 participants, very low quality evidence), the need for blood transfusion (two trials, 89 participants, very low quality evidence), pulmonary haemorrhage (one trial, 63 participants, very low quality evidence), convulsions (one trial, 63 participants, very low quality evidence), or duration of hospitalization (one trial, 63 participants, very low quality evidence). The body of evidence is too small to confidently prove or exclude clinically important effects. Furthermore, the trials are more than 20 years old with several methodological limitations.

Patients with dengue at an early stage

Four studies enrolled 664 children and adults with dengue at an early stage of infection (without shock) in Columbia, India, Sri Lanka and Vietnam. In these participants there were no evidence of effects of oral or intravenous corticosteroids on mortality (four trials, 664 participants, low quality evidence), or on the development of complications of severe dengue such as shock (two trials, 286 participants, very low quality evidence), severe bleeding (two trials, 425 participants, very low quality evidence), severe thrombocytopaenia (one trial, 225 participants, very low quality evidence), ascites (one trial, 178 participants, very low quality evidence) and intensive care unit (ICU) admissions (two trials, 286 participants, very low quality evidence).

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