What is the recommended approach to steroid use in patients with latent tuberculosis (TB) and uveitis?

Steroid Use in Latent TB with Uveitis

Patients with latent tuberculosis and uveitis should receive anti-tubercular therapy (ATT) before or concurrent with corticosteroid treatment to prevent TB reactivation and reduce uveitis recurrence. 1, 2

Mandatory Pre-Treatment Screening

Before initiating any immunosuppressive therapy for uveitis, you must screen for latent or active tuberculosis, as history of tuberculosis is a specific contraindication to corticosteroid therapy that must be addressed. 1, 3

• Screen all patients for latent/active TB before starting corticosteroids or other immunosuppressive agents using tuberculin skin testing or interferon-gamma release assays (T-SPOT.TB). 1, 3
• Additional baseline screening should include hepatitis B and C, HIV testing, complete blood count, liver function, and renal function tests. 3, 4

Treatment Algorithm for Latent TB with Uveitis

Step 1: Initiate Anti-Tubercular Therapy First

• Start ATT before or simultaneously with corticosteroids in all patients with latent TB and uveitis to prevent reactivation. 2, 5
• The FDA label for prednisone explicitly warns that "if prednisone tablets is used to treat a condition in patients with latent tuberculosis or tuberculin reactivity, reactivation of tuberculosis may occur" and recommends chemoprophylaxis during prolonged therapy. 2
• Use a four-drug ATT regimen (typically isoniazid, rifampin, pyrazinamide, and ethambutol) for optimal outcomes. 5, 6

Step 2: Determine ATT Duration

• Treat for >9 months to achieve maximum reduction in uveitis recurrence—this provides an 11-fold reduction in recurrence likelihood compared to shorter durations. 7
• Patients completing >9 months of ATT had significantly lower recurrence rates (OR 0.09; 95% CI 0.01-0.76) compared to those not treated with ATT. 7
• Standard 6-month courses are insufficient; extending beyond 9 months provides superior long-term control. 7

Step 3: Add Corticosteroids for Inflammation Control

• Combine corticosteroids with ATT, never use corticosteroids alone in TB-associated uveitis. 5, 8
• Patients receiving ATT plus corticosteroids had 15.74% recurrence rates versus 46.53% with corticosteroids alone (P<0.001), representing a two-thirds reduction in recurrence risk. 5
• For anterior uveitis: Use topical prednisolone acetate 1% with mydriatics, limiting to ≤3 drops daily during maintenance to minimize glaucoma and cataract risk. 3, 4, 6
• For posterior/intermediate uveitis: Systemic corticosteroids are required but must always be combined with immunosuppressive agents (ATT in this case), never as monotherapy. 3, 4

Step 4: Consider Steroid-Sparing Immunosuppression

If corticosteroid-dependent inflammation persists despite ATT:

• Add methotrexate (0.5-1 mg/kg/week, maximum 30 mg) as first-line steroid-sparing agent. 3, 4
• Alternative options include mycophenolate mofetil or azathioprine. 3, 4
• For refractory cases, adalimumab (TNF-α inhibitor) is the preferred biologic, but requires continued TB screening and monitoring. 3, 4

Step 5: Local Therapy for Macular Edema

• Intravitreal dexamethasone implants can safely control inflammation and macular edema in TB uveitis when systemic/periocular steroids provide inadequate control. 9
• This approach provides potent local anti-inflammatory effect while minimizing systemic immunosuppression. 9

Critical Monitoring Requirements

• Monitor closely for TB reactivation during the first 4-6 weeks of treatment, when paradoxical inflammatory worsening commonly occurs. 9
• Continue ophthalmologic monitoring for at least 3 years after remission to detect recurrence. 3, 4
• Watch for corticosteroid-induced complications: elevated intraocular pressure (especially with >2 drops/day topical prednisolone) and cataract formation. 3, 4

Common Pitfalls to Avoid

• Never use corticosteroids alone without ATT in latent TB—this increases recurrence risk by 3-fold and risks systemic TB reactivation. 5
• Do not use short ATT courses (<6 months)—these provide inadequate protection against recurrence. 7
• Avoid etanercept as a biologic option, as it has no efficacy and may paradoxically worsen uveitis. 4
• Do not delay ATT while waiting for inflammation to improve—start ATT immediately upon diagnosis of latent TB. 2, 5