THE USE OF STEROIDS IN TUBERCULOSIS

Despite the availability of effective drugs against TB, many patients still suffer the consequences of the host?s immune response to mycobacterial infection. This inflammation, often followed by fibrosis, may lead to organ dysfunction and result in permanent pathophysiological sequelae. The adjunctive use of steroids in TB would seem to be a reasonable strategy to minimize this and to improve outcome. Appraisal of medical literature reveals that there is a paucity of controlled, randomised trials investigating the potential benefit of steroids. Even more so, there is a dearth of reports in HIV positive patients with TB. The dose, duration and type of steroid used in reported studies vary considerably. It should also be noted that Rifampicin induces the metabolism of steroids (intended dose of steroids should be approximately doubled whilst the patient is receiving Rifampicin).

Clinical situations where steroids have been shown to have benefit

Adrenal insufficiency due to TB (Suggested dose: Hydrocortisone 100 ? 200 mg IV 6
hourly in acute phase; then maintenance dose of Prednisone 15 mg PO mane).

TB meningitis (decreased mortality)
Steroids result in more rapid resolution of constitutional symptoms
Clinical situations where steroids have possible benefit

TB pericarditis (reduces size of pericardial effusion and rate of reaccumulation)
(Suggested dose: Prednisone 60 mg daily, tapered over 6 ? 12 weeks)

TB lymphadenitis causing compressive symptoms
(Suggested dose: Prednisone 30 ? 60 mg daily, tapered over 4 ? 6 weeks)

?Paradoxical response? to TB therapy (immune reconstitution)
(Suggested dose: Prednisone 30 ? 60 mg daily, tapered over 2 ? 6 weeks)

Clinical situations where steroids have not been shown to be of benefit (may be due to small number of patients in reported studies)

Steroids do not increase the time to sputum negativity, nor the rate of long-term cure.
TB pleuritis (resolution of effusion may be hastened, but no difference in long-term residual pleural thickening)
Steroids do not reduce the likelihood of pericardial constriction in TB pericarditis.
Miliary TB (unless there is associated adrenal insufficiency)
The adjunctive use of steroids in TB may be definitively advocated only in patients with adrenal TB and TB meningitis. Additional reasonable indications are pericarditis, lymphadenitis associated with compressive symptoms, and prominent persistent constitutional symptoms. Little data is available for HIV positive patients with TB