When are steroids, such as prednisolone (corticosteroid), indicated for patients with tuberculosis (TB)?

Indications for Corticosteroids in Tuberculosis Treatment

Corticosteroids are indicated in specific forms of tuberculosis, particularly tuberculous meningitis, and selectively in tuberculous pericarditis with high risk of inflammatory complications, but should not be routinely used for other forms of TB due to limited evidence of benefit and potential risks.

Tuberculous Meningitis

• Strong recommendation for adjunctive corticosteroid therapy with dexamethasone or prednisolone tapered over 6-8 weeks for all patients with tuberculous meningitis 1
• Corticosteroids have demonstrated mortality benefits in tuberculous meningitis and are considered standard of care 1
• For adults, dexamethasone should be administered at an initial dose of 12 mg/day for 3 weeks, then gradually decreased over the following 3 weeks 1
• For children weighing less than 25 kg, the recommended dexamethasone dose is 8 mg/day, with the same tapering schedule 1
• Patients with decreased level of consciousness particularly benefit from corticosteroid therapy 1

Tuberculous Pericarditis

• Current guidelines suggest not routinely using adjunctive corticosteroids in patients with tuberculous pericarditis (conditional recommendation; very low certainty in evidence) 1
• Selective use may be appropriate for patients at highest risk for inflammatory complications, including: 1
  • Those with large pericardial effusions
  • Those with high levels of inflammatory cells or markers in pericardial fluid
  • Those with early signs of constriction
• Older guidelines (2003) had recommended corticosteroids for tuberculous pericarditis, but more recent evidence from a large randomized trial with 1400 participants did not find significant benefit for the combined primary endpoint of mortality, cardiac tamponade, or constrictive pericarditis 1
• If corticosteroids are used, the recommended adult dose is prednisone 60 mg/day for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and 5 mg/day for the final week 1

Tuberculous Pleural Effusion

• Adjunctive corticosteroids are not recommended for routine use in tuberculous pleural effusions 1
• Multiple randomized controlled trials have shown that prednisone does not provide significant long-term benefits in preventing pleural thickening or other sequelae 1
• While some studies showed more rapid symptom resolution and radiographic improvement with corticosteroids, the clinical significance is unclear 1
• In HIV-infected patients with tuberculous pleurisy, corticosteroids may increase the risk of Kaposi sarcoma 1, 2

Other Forms of Tuberculosis

• Pulmonary TB: No strong evidence supports routine use of corticosteroids in uncomplicated pulmonary tuberculosis 3
• Spinal TB with meningitis: Managed as tuberculous meningitis, including consideration of adjunctive corticosteroids 1
• Disseminated/Miliary TB: Expert opinion suggests corticosteroids may be useful for treating respiratory failure caused by disseminated tuberculosis, but evidence is limited 1
• Tuberculous lymphadenitis: Limited evidence suggests potential benefit, but not routinely recommended 4
• TB-IRIS (Immune Reconstitution Inflammatory Syndrome): Corticosteroids are beneficial in HIV patients with paradoxical TB-IRIS 1, 5
  • For moderate to severe IRIS, prednisone 1.25 mg/kg/day has been shown to reduce need for hospitalization 1

Important Considerations and Cautions

• Corticosteroids must always be used in conjunction with appropriate anti-tuberculosis drug regimens 6
• In active tuberculosis, prednisolone should be restricted to cases of fulminating or disseminated tuberculosis where corticosteroid is used for disease management alongside appropriate anti-tuberculous treatment 6
• Patients on corticosteroids have increased susceptibility to infections, and TB may be activated or exacerbated 6
• Monitoring for adverse effects of corticosteroids is essential, including hyperglycemia, hypertension, and opportunistic infections 6
• HIV-positive TB patients receiving corticosteroids may have increased risk of herpes zoster and Kaposi's sarcoma 2

Dosing Recommendations When Indicated

• Tuberculous meningitis: Dexamethasone 12 mg/day (adults) or 8 mg/day (children <25 kg) for 3 weeks, then tapered over 3 weeks 1
• Tuberculous pericarditis (when indicated): Prednisone 60 mg/day for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and 5 mg/day for week 11 1
• TB-IRIS: Prednisone 1.25 mg/kg/day with tapering over several weeks 1, 5