What is the recommended dose of steroids, specifically prednisolone, in the treatment of tubercular meningitis?

Steroid Dosing in Tuberculous Meningitis

For tuberculous meningitis, dexamethasone 0.4 mg/kg/day (maximum 12 mg/day) intravenously for the first 3 weeks, followed by gradual tapering over the next 3 weeks, or prednisolone 60 mg/day with gradual tapering over 6-8 weeks is strongly recommended. 1

Adult Dosing Options

Dexamethasone Regimen

• Initial dose: 0.4 mg/kg/day IV with maximum of 12 mg/day 1
• Duration: Intravenous administration for first 3 weeks 1
• Tapering: Gradually decrease over the following 3 weeks (total 6 weeks of therapy) 1

Prednisolone Regimen

• Initial dose: 60 mg/day 1
• Tapering schedule: Gradually over 6-8 weeks 1
• Alternative tapering schedule: 60 mg/day for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and finally 5 mg/day for week 11 (the final week) 2

Pediatric Dosing

• Children weighing <25 kg: Dexamethasone 8 mg/day 1
• Children weighing ≥25 kg: Dexamethasone 12 mg/day (same as adult dose) 1
• Alternative approach: Prednisolone at doses proportionate to body weight, beginning with about 1 mg/kg body weight and decreasing as described for adults 2
• Duration: Initial dose for 3 weeks, then gradually decreased over the following 3 weeks 1

Clinical Considerations

Timing of Steroid Initiation

• Corticosteroids should be initiated before or concurrently with the first dose of anti-tuberculosis medication for maximum benefit 1
• Early administration is associated with better outcomes in terms of mortality reduction 3

Duration of Anti-TB Treatment

• Standard anti-TB therapy for meningitis should be continued for 9-12 months total 1
• Initial phase: INH, RIF, PZA, and EMB for 2 months 1
• Continuation phase: INH and RIF for an additional 7-10 months 1

Monitoring

• Regular monitoring of cerebrospinal fluid parameters through repeated lumbar punctures should be considered, especially early in the course of therapy 1
• Monitor for common adverse events including gastrointestinal bleeding, invasive bacterial infections, hyperglycemia, and liver dysfunction 3

Evidence for Steroid Use

• Corticosteroids reduce mortality from tuberculous meningitis by almost one quarter (RR 0.75,95% CI 0.65 to 0.87) based on high-quality evidence 3
• The mortality benefit may not persist at 5-year follow-up (RR 0.93,95% CI 0.78 to 1.12) 3
• Steroids may have little or no effect on disabling neurological deficit in survivors (RR 0.92,95% CI 0.71 to 1.20) 3

Special Considerations

• Use corticosteroids with caution in HIV-infected patients 2
• Evidence for steroid benefit in HIV-positive individuals with TB meningitis is limited, but point estimates for mortality benefit appear similar to HIV-negative patients 3
• Some clinicians have explored alternative approaches with shorter IV steroid courses (median 9 days) followed by oral steroids after 48 hours of sustained improvement, with reported mortality rates of 6.1% 4

The evidence strongly supports the use of corticosteroids in tuberculous meningitis to reduce mortality, with dexamethasone and prednisolone being the most studied options with established dosing regimens.