Can a trial of prednisolone (corticosteroid) 20 mg be done in a 46 kg patient with tuberculosis (TB) pleurisy, currently in the continuation phase, without cough or fever, and will it improve appetite?

Prednisolone for TB Pleurisy in Continuation Phase

Prednisolone is not recommended for TB pleurisy in the continuation phase for appetite improvement, as multiple randomized controlled trials have shown no benefit, and it may pose unnecessary risks.

Evidence Against Corticosteroids in TB Pleurisy

The most recent guidelines from the American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America (2016) clearly state that there is no evidence to support the routine use of adjunctive corticosteroids in patients with tuberculous pleurisy 1. This recommendation is based on multiple prospective, double-blind, randomized controlled trials that consistently showed:

• No beneficial effect on residual pleural thickening or prevention of other long-term pleural sequelae
• No significant improvement in appetite specifically
• Potential risks, including increased risk of infections in immunosuppressed patients

Specific Evidence from Clinical Trials

Four prospective, double-blind, randomized controlled trials have examined the use of corticosteroids in TB pleurisy 1:

• In all studies, prednisone/prednisolone did not confer a beneficial effect on residual pleural thickening or prevention of long-term pleural sequelae
• One study showed an increased risk for Kaposi sarcoma with prednisolone use in HIV-associated tuberculous pleurisy 1
• While some studies showed earlier symptomatic improvement with corticosteroids, the overall clinical outcomes were similar between corticosteroid and placebo groups 2

Risks of Prednisolone in TB Patients

The FDA label for prednisolone highlights several important risks 3:

• Increased susceptibility to infections
• Potential for activation of latent TB or exacerbation of intercurrent infections
• Masking of infection signs
• Potential for serious complications in patients with latent or active infections

Appropriate Management for TB Pleurisy

For TB pleurisy, the recommended approach is:

1. Complete the standard 6-month anti-TB regimen for pleural tuberculosis 1
2. Focus on adequate nutrition through dietary improvements rather than corticosteroids for appetite enhancement
3. Monitor for resolution of the pleural effusion through regular clinical and radiological assessment

Special Considerations

• For a patient in the continuation phase with no cough or fever, adding prednisolone provides no additional benefit for appetite improvement
• Weight of 46 kg suggests the patient may already be undernourished, making proper nutrition important, but corticosteroids are not the appropriate intervention
• If appetite remains poor, consider nutritional consultation and addressing other potential causes of poor appetite

Conclusion

Based on the highest quality evidence from multiple randomized controlled trials and current clinical guidelines, prednisolone should not be used for TB pleurisy in the continuation phase to improve appetite, as it provides no proven benefit and carries potential risks.