Prednisolone Dosing in Tubercular Meningitis
The recommended dose of Omnacortil (prednisolone) in tubercular meningitis is 60 mg/day for adults, tapered over 6-8 weeks. 1
Corticosteroid Regimen Details
Corticosteroids are strongly recommended as adjunctive therapy in tubercular meningitis (TBM) based on high-quality evidence showing approximately 25% reduction in mortality. The standard prednisolone regimen consists of:
- Initial dose: 60 mg/day for adults 1
- Duration: 6-8 weeks total, with gradual tapering 1
- Administration: Oral administration for most patients; intravenous administration for critically ill patients or those with altered mental status
Alternative Corticosteroid Option
Dexamethasone can be used as an alternative at 12 mg/day, also tapered over 6-8 weeks 1, 2
Treatment Algorithm Based on Disease Severity
1. Assess Disease Severity
Use British Medical Research Council staging system:
- Stage I: Alert and oriented with no focal neurological deficits
- Stage II: Confused or has neurological signs (cranial nerve palsy, hemiparesis)
- Stage III: Comatose or stuporous with severe neurological signs (GCS ≤10)
2. Initiate Anti-Tubercular Therapy
Standard regimen consists of:
- Initial phase (2 months): Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol
- Continuation phase (7-10 months): Isoniazid and Rifampicin
- Total duration: 9-12 months 1
3. Add Corticosteroid Therapy
- For all TBM patients: Prednisolone 60 mg/day or Dexamethasone 12 mg/day 1
- Taper schedule: Gradually over 6-8 weeks
- Monitoring: Watch for rebound inflammation if tapered too rapidly
4. Consider Additional Adjunctive Therapy
- Aspirin: 81-150 mg daily (low dose) to 600-1200 mg daily (high dose) for moderate to severe disease (Stages II and III) 1, 3
- Duration: Continue throughout intensive phase (first 2 months) 1
Monitoring and Complications
Regular Monitoring
- Neurological assessment
- Blood glucose levels (especially in diabetic patients)
- Signs of steroid-related adverse effects
- Follow-up neuroimaging to assess for infarctions and hydrocephalus
Potential Complications
- Hydrocephalus: May require neurosurgical intervention 1
- Paradoxical reactions: May occur during treatment and require increased or reintroduced corticosteroids 4
- Steroid-related adverse effects: Hyperglycemia, gastrointestinal bleeding, secondary infections, hypertension 1
Special Considerations
Tapering Schedule
- Do not taper too rapidly to avoid rebound inflammation
- Consider slower tapering in patients with severe disease or those showing slow clinical improvement
HIV Co-infection
- Corticosteroids are still recommended in HIV-infected individuals with TBM 1, 5
- HIV-positive patients may require longer courses of anti-tubercular therapy
Cautions
- Regular monitoring for steroid-related complications is essential
- Patients on corticosteroids are more susceptible to infections, which may be masked by steroid therapy
- Ethambutol should be used with caution in unconscious patients (Stage III) as visual acuity cannot be tested 1
The evidence strongly supports the use of corticosteroids in TBM, with prednisolone 60 mg/day being a standard recommended dose that has demonstrated significant mortality benefit in this serious condition.