What are the guidelines for using steroids in tuberculosis (TB) pericarditis?

NTEP Guidelines on Steroids in TB Pericarditis

Adjunctive corticosteroids should NOT be routinely used in tuberculous pericarditis, based on the most recent American Thoracic Society/CDC/IDSA guidelines which found no mortality benefit in a large randomized trial of 1,400 patients. 1

Primary Recommendation

• The 2016 ATS/CDC/IDSA guidelines explicitly recommend AGAINST routine use of adjunctive corticosteroids in tuberculous pericarditis (conditional recommendation, very low certainty evidence). 1
• This represents a significant shift from previous practice, as a large placebo-controlled trial with 1,400 participants found no difference in the combined endpoint of mortality, cardiac tamponade, or constrictive pericarditis between steroid and placebo groups. 1
• A systematic review conducted for these guidelines similarly found no statistically significant mortality or constrictive pericarditis benefit from corticosteroids. 1

Selective Use in High-Risk Patients

However, selective use may be appropriate in patients at highest risk for inflammatory complications: 1

• Patients with large pericardial effusions 1, 2
• Those with high levels of inflammatory cells or markers in pericardial fluid 1, 2
• Patients with early signs of constriction 1, 2
• HIV-negative patients only - the European Society of Cardiology recommends considering steroids in HIV-negative cases while avoiding them in HIV-positive patients due to increased malignancy risk 1

Steroid Regimen When Used

If steroids are used in selected high-risk patients, the recommended 11-week tapering schedule is: 2

• Weeks 1-4: Prednisone 60 mg/day (or equivalent prednisolone dose) 2
• Weeks 5-8: 30 mg/day 2
• Weeks 9-10: 15 mg/day 2
• Week 11: 5 mg/day (final week) 2
• For children: weight-proportionate dosing starting at approximately 1 mg/kg body weight with the same tapering pattern 2

Critical Contraindications and Precautions

Steroids must ALWAYS be used with appropriate antituberculous chemotherapy - never alone: 3

• The FDA label for prednisolone explicitly states use in active tuberculosis should be restricted to fulminating or disseminated disease and MUST be used in conjunction with appropriate antituberculous regimen. 3
• Avoid in HIV-positive patients due to increased risk of malignancy and Kaposi sarcoma. 1
• Close observation is necessary as corticosteroids may mask signs of infection and increase susceptibility to opportunistic infections. 3

Evidence Quality and Nuances

The evidence presents important contradictions:

• Older studies showed benefit: A 1987 controlled trial in Transkei showed prednisolone significantly improved outcomes, with only 4% mortality in the steroid group versus 11% in placebo, and reduced need for pericardiectomy (21% vs 30%). 4
• Recent large trial showed no benefit: The most recent and largest trial (1,400 patients) found no difference in primary endpoints, though subgroup analysis suggested possible benefit in preventing constrictive pericarditis. 1
• ESC guidelines are more permissive: The 2015 European Society of Cardiology guidelines give a IIb recommendation (may be considered) for adjunctive steroids in HIV-negative cases, based on earlier evidence showing reduced constriction and hospitalization. 1

Common Pitfalls to Avoid

• Do not use steroids routinely - the default should be antituberculous therapy alone unless specific high-risk features are present. 1
• Never use steroids without concurrent antituberculous drugs - this is explicitly contraindicated and dangerous. 3
• Do not use in HIV-positive patients - the risk-benefit ratio is unfavorable due to malignancy risk. 1
• Recognize that untreated tuberculous pericarditis has 85% mortality - the priority is effective antituberculous therapy, not steroids. 5
• Be aware that even with treatment, TB pericarditis carries 17-40% mortality at 6 months - steroids have not been shown to improve this in recent high-quality evidence. 5