What are the indications for steroid use in tuberculosis?

Indications for Steroid Use in Tuberculosis

Adjunctive corticosteroid therapy is strongly indicated in tuberculous meningitis and tuberculous pericarditis, but not routinely recommended for other forms of tuberculosis unless specific complications are present. 1

Specific Indications by TB Location

1. Tuberculous Meningitis

• Strong indication for corticosteroids 1
  • Reduces mortality and morbidity
  • Recommended for all patients, particularly those with decreased level of consciousness
  • Dosing regimen:
    • Adults: Dexamethasone 12 mg/day or prednisolone equivalent
    • Children <25 kg: Dexamethasone 8 mg/day
    • Duration: Initial dose for 3 weeks, then tapered over the following 3-6 weeks
  • Mortality benefit clearly established through multiple controlled trials 1, 2

2. Tuberculous Pericarditis

• Strong indication for corticosteroids 1
  • Reduces need for repeated pericardiocentesis
  • Reduces mortality (3% vs 14%, p<0.05)
  • Dosing regimen:
    • Adults: Prednisone 60 mg/day for 4 weeks, then 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and 5 mg/day for the final week
    • Children: ~1 mg/kg body weight with similar tapering schedule
  • Note: More recent guidelines suggest a more selective approach, though earlier studies showed clear benefits 1

3. Disseminated/Miliary Tuberculosis

• Conditional indication for corticosteroids 1
  • May be beneficial for:
    • Severe respiratory failure
    • Adrenal insufficiency caused by disseminated TB
  • Limited data from controlled clinical trials
  • Expert opinion supports use in severe cases

4. Pleural Tuberculosis

• Not routinely indicated 1
  • May be considered for:
    • Significant systemic symptoms (fever)
    • Particularly large effusions
    • Rapid symptom resolution
  • Corticosteroids reduce pleural thickening but clinical significance is unclear 3

5. Genitourinary Tuberculosis

• Not routinely indicated 1
  • Standard 6-month antituberculous regimen is adequate
  • Some urologic literature discusses steroids for ureteric stenosis, but efficacy is unclear

6. Abdominal Tuberculosis

• Not routinely indicated 1
  • Insufficient data to recommend adjunctive corticosteroid therapy
  • Small studies suggest possible reduction in fibrotic complications but results not statistically significant

7. Lymph Node Tuberculosis

• Not indicated 1
  • Therapeutic lymph node excision not indicated except in unusual circumstances

8. Bone and Joint Tuberculosis

• Not indicated 1
  • Standard 6-9 month regimen containing rifampin is adequate

Special Considerations

HIV Co-infection

• Corticosteroids generally recommended for TB meningitis and pericarditis even in HIV co-infected patients 3
• Beneficial for paradoxical TB immune reconstitution inflammatory syndrome (IRIS) 3

Dosing Considerations

• For TB meningitis, evidence suggests that moderate doses (prednisolone 4 mg/kg/day for 1 week followed by 2 mg/kg/day for 3 weeks) may be optimal 4
• Prolonged high-dose steroids may increase risk of optic atrophy and hydrocephalus 4
• IV steroids can potentially be switched to oral earlier in select patients with TB meningitis who show sustained improvement 5

Important Cautions

• Corticosteroids must always be used in conjunction with appropriate antituberculous regimen 6
• Patients on corticosteroids are more susceptible to infections
• May mask signs of infection progression
• Reactivation risk in latent TB - chemoprophylaxis recommended during prolonged therapy 6
• Contraindicated in cerebral malaria 6

Monitoring

• For TB meningitis, repeated lumbar punctures should be considered to monitor changes in CSF cell count, glucose, and protein, especially early in the course of therapy 1
• Monitor for steroid-related adverse effects, particularly in prolonged use

Remember that corticosteroids should never be used as monotherapy for tuberculosis but always as an adjunct to appropriate antituberculous chemotherapy.