Recommended Steroid Dosing for TB Meningitis
For patients with tuberculous meningitis, adjunctive corticosteroid therapy with dexamethasone or prednisolone tapered over 6-8 weeks is strongly recommended to reduce mortality.1
Adult Dosing Regimen
Dexamethasone Option
- Initial dose: 0.4 mg/kg/day for adults with a maximum of 12 mg/day 1
- Administration: Given intravenously for the first 3 weeks 1
- Tapering schedule: Gradually decrease over the following 3 weeks (total 6 weeks of therapy) 1
Prednisolone Option
- Initial dose: High-dose prednisolone 60 mg/day 2
- Tapering schedule: Gradually tapered over 6-8 weeks 1
Pediatric Dosing Regimen
- For children weighing less than 25 kg: Dexamethasone 8 mg/day 1
- For children weighing 25 kg or more: Dexamethasone 12 mg/day (same as adult dose) 1
- Duration: Initial dose for 3 weeks, then gradually decreased over the following 3 weeks 1
- Alternative: Weight-based dosing of approximately 1 mg/kg of prednisone daily 3
Evidence and Rationale
- Multiple systematic reviews and controlled trials have demonstrated that corticosteroids reduce mortality in tuberculous meningitis by approximately 25% 4
- The American Thoracic Society, CDC, and Infectious Diseases Society of America strongly recommend adjunctive corticosteroids for TB meningitis based on moderate certainty evidence 1
- Corticosteroids should be initiated before or concurrently with the first dose of anti-tuberculosis medication for maximum benefit 1
- The mortality benefit is most pronounced in the short term (3-18 months), though the effect may diminish over longer follow-up periods 4
Important Considerations
- Corticosteroids appear to have little effect on preventing disabling neurological deficits among survivors, but the mortality benefit outweighs this consideration 4
- Adverse events including gastrointestinal bleeding, hyperglycemia, and liver dysfunction do not appear to differ significantly between corticosteroid and control groups 4
- For patients with HIV and TB meningitis, the evidence is more limited but suggests similar benefits from corticosteroid therapy 4
- Regular monitoring of cerebrospinal fluid parameters through repeated lumbar punctures should be considered, especially early in the course of therapy 1