What are the indications for steroid use in tuberculosis?

Indications for Steroids in Tuberculosis

Steroids are definitively indicated for tuberculous meningitis and tuberculous pericarditis, and should always be used as adjunctive therapy alongside appropriate antituberculous chemotherapy to reduce mortality and morbidity. 1

Primary Indications for Corticosteroid Therapy

Tuberculous Meningitis

• Recommended for all patients with tuberculous meningitis 1
• Dosing regimen:
  • Adults: Dexamethasone 12 mg/day or prednisolone equivalent
  • Children under 25 kg: Dexamethasone 8 mg/day
  • Duration: Initial 3 weeks, then tapered over 3-6 weeks 1
• Reduces mortality and improves outcomes, particularly in patients with decreased level of consciousness 1

Tuberculous Pericarditis

• Reduces need for repeated pericardiocentesis and mortality 1
• Dosing regimen for adults:
  • Prednisone 60 mg/day for 4 weeks
  • Then 30 mg/day for 4 weeks
  • Then 15 mg/day for 2 weeks
  • Finally 5 mg/day for 1 week 1

Other Specific Indications

Fulminating or Disseminated Tuberculosis

• Corticosteroids are indicated when used concurrently with appropriate antituberculous chemotherapy 2
• The use of prednisolone should be restricted to cases of fulminating or disseminated tuberculosis where it's used for disease management alongside antituberculous treatment 2

Tuberculosis with Respiratory Complications

• Indicated for tuberculosis with enlarged mediastinal lymph nodes causing respiratory difficulty 2
• Indicated for tuberculosis with pleural or pericardial effusion 2

Severe Respiratory Failure from TB

• May be beneficial, though limited data is available from controlled clinical trials 1

Adrenal Insufficiency from Disseminated TB

• Corticosteroids are indicated when adrenal suppression is a concern 3

Conditional Indications

Tuberculous Pleural Effusion

• Not routinely required unless there are significant systemic symptoms of fever or particularly large effusions 3
• Corticosteroids significantly decrease the risk of pleural thickening, though the clinical significance is unclear 4

Important Precautions and Contraindications

1. Never use as monotherapy:

   • Corticosteroids should never be used alone for tuberculosis treatment 1
   • Always administer with appropriate antituberculous chemotherapy 1, 2

2. Latent TB concerns:

   • Close observation is necessary in patients with latent tuberculosis or tuberculin reactivity as reactivation may occur 2
   • During prolonged corticosteroid therapy, chemoprophylaxis should be provided 2

3. Infection risks:

   • Corticosteroids may mask signs of infection progression 1
   • Patients on corticosteroids are more susceptible to infections 2
   • May activate latent disease or exacerbate intercurrent infections 2

4. Vaccination considerations:

   • Live or live-attenuated vaccines are contraindicated in patients receiving immunosuppressive doses of corticosteroids 2

Monitoring Recommendations

• Monitor for steroid-related adverse effects, particularly during prolonged use 1
• In TB meningitis, consider repeated lumbar punctures to monitor changes in CSF cell count, glucose, and protein 1
• Observe for signs of infection progression that may be masked by steroid therapy 1

Dosing Considerations

• For most forms of TB requiring steroids, the usual dose is 40-60 mg of prednisone orally daily for 4-6 weeks, followed by tapering doses 3
• In tuberculous meningitis, evidence suggests that prednisolone at 2 mg/kg/day is associated with lower risk of mental retardation and spasticity compared to higher doses 5
• Some evidence suggests that IV steroid duration can be reduced in TB meningitis patients by shifting to oral steroids after 48 hours of sustained improvement 6

Common Pitfalls to Avoid

1. Using steroids without concurrent antituberculous therapy
2. Failing to provide chemoprophylaxis during prolonged steroid therapy
3. Not monitoring for steroid-related adverse effects
4. Overlooking the risk of activating latent infections
5. Using steroids in cerebral malaria, which is contraindicated 2

Remember that while steroids have proven benefits in specific forms of tuberculosis, they should be used judiciously and always in conjunction with appropriate antituberculous therapy.