What is the role of aspirin (acetylsalicylic acid) in the treatment of Tuberculosis (TB) meningitis?

Role of Aspirin in Tuberculous Meningitis Treatment

Aspirin (acetylsalicylic acid) is recommended as an adjunctive therapy in tuberculous meningitis, particularly for patients with moderate to severe disease (stages II and III), as it may reduce mortality and morbidity by preventing infarctions and reducing inflammation.

Standard Treatment for TB Meningitis

The cornerstone of TB meningitis treatment consists of:

1. Antitubercular therapy:

   • Initial phase (2 months): Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol
   • Continuation phase (7-10 months): Isoniazid and Rifampicin
   • Total duration: 9-12 months 1, 2

2. Adjunctive corticosteroids:

   • Strongly recommended for all TB meningitis patients 1, 2
   • Dexamethasone (12 mg/day) or Prednisolone (60 mg/day), tapered over 6-8 weeks
   • Reduces mortality by approximately 25% 2

Role of Aspirin in TB Meningitis

Aspirin serves as an important adjunctive therapy in TB meningitis due to its:

1. Anti-inflammatory effects: Reduces the inflammatory response in the meninges
2. Antiplatelet effects: Prevents cerebral infarctions, which are common complications

Evidence for Aspirin Use

While not explicitly mentioned in the older guidelines 1, more recent evidence supports the use of aspirin in TB meningitis:

• Aspirin has been shown to reduce the risk of stroke and mortality in TB meningitis patients by preventing the development of cerebral infarctions
• It addresses the vasculopathy component of TB meningitis that can lead to strokes and permanent neurological damage
• Most beneficial in moderate to severe cases (stages II and III) where the risk of infarction is highest

Recommended Dosing

• Adults: 81-150 mg daily (low dose) or 600-1200 mg daily (high dose) depending on severity and risk of infarction
• Continue throughout the intensive phase of TB treatment (first 2 months)

Comprehensive Management Approach

For optimal TB meningitis management:

1. Classify disease severity using British Medical Research Council staging:

   • Stage I: Alert and oriented with no focal neurological deficits
   • Stage II: Glasgow Coma Scale 11-14 or focal neurological deficits
   • Stage III: Glasgow Coma Scale ≤10 2, 3

2. Initiate standard antitubercular therapy immediately upon clinical suspicion 1, 2

3. Add adjunctive therapies:

   • Corticosteroids (dexamethasone or prednisolone) for all patients 1, 2
   • Aspirin for patients with moderate to severe disease or those at high risk of infarctions
   • Consider neurosurgical consultation for hydrocephalus 2

4. Monitor closely:

   • Regular neurological assessment
   • Follow-up neuroimaging to assess for infarctions and hydrocephalus
   • Repeated lumbar punctures to monitor CSF changes 1, 2

Potential Complications and Considerations

• Bleeding risk: Monitor for signs of bleeding, particularly with higher doses of aspirin
• Drug interactions: Aspirin may interact with corticosteroids, increasing the risk of gastrointestinal bleeding
• Reye's syndrome: Avoid aspirin in children and adolescents with viral infections

Conclusion

While corticosteroids remain the primary adjunctive therapy for TB meningitis with strong evidence supporting their use 1, 2, aspirin represents an important additional intervention that can improve outcomes by addressing the vascular complications of the disease. The decision to use aspirin should be based on disease severity, risk of infarction, and individual bleeding risk.