When should steroids be given to patients with tuberculosis (TB), particularly those with severe forms such as TB meningitis or miliary TB?

When to Give Steroids in Tuberculosis

Adjunctive corticosteroids should be given to all patients with tuberculous meningitis (particularly those with decreased consciousness) and to patients with TB spine complicated by spinal cord compression; steroids are NOT routinely recommended for tuberculous pericarditis, pleural TB, or uncomplicated pulmonary TB. 1, 2, 3

Definitive Indications for Steroids

Tuberculous Meningitis (STRONGEST INDICATION)

• All patients with TB meningitis should receive adjunctive dexamethasone or prednisolone, with the greatest benefit in those with decreased level of consciousness. 1, 4
• Steroids reduce mortality by approximately 25% (mortality 15% vs 40% in controls for Stage II disease). 1, 4, 5
• The mortality benefit is most pronounced in patients with Stage II disease (lethargic presentation), though benefit exists across severity stages. 1, 4

Dosing regimen:

• Adults and children ≥25 kg: Dexamethasone 12 mg/day OR prednisolone 60 mg/day 1, 2, 4
• Children <25 kg: Dexamethasone 8 mg/day 1, 2, 4
• Duration: Initial dose for 3 weeks, then taper gradually over the following 3 weeks (total 6-8 weeks) 1, 4
• Initiate steroids before or concurrently with first dose of anti-TB medication to maximize benefit. 4

TB Spine with Spinal Cord Compression

• Corticosteroids are specifically indicated when there is evidence of spinal cord compression, with the goal of reducing inflammation and preventing or reversing neurological deficits. 2
• Use the same dexamethasone dosing as TB meningitis: 12 mg/day for adults (8 mg/day for children <25 kg) for 3 weeks, then taper over 3 weeks. 2
• Steroids do NOT replace surgical intervention when indicated (progressive deficits, spinal instability, or failure of medical therapy). 2

Conditional/Selective Use

Tuberculous Pericarditis

• Adjunctive corticosteroids should NOT be routinely used in tuberculous pericarditis (conditional recommendation based on very low certainty evidence). 1, 3
• A large randomized trial with 1400 participants found no difference in the combined endpoint of mortality, cardiac tamponade, or constrictive pericarditis. 1
• Selective use may be appropriate in highest-risk patients: those with large pericardial effusions, high inflammatory markers in pericardial fluid, or early signs of constriction. 1

Disseminated/Miliary Tuberculosis

• Expert opinion suggests corticosteroids may be useful for respiratory failure caused by disseminated TB, but there are no data to support routine use. 1
• Standard 6-month anti-TB regimen is recommended without routine steroids. 1

Paradoxical TB-IRIS (in HIV-positive patients)

• For moderate to severe IRIS, prednisone 1.25 mg/kg/day significantly reduces need for hospitalization or surgical intervention. 1
• Mild IRIS can be managed with anti-inflammatory agents like ibuprofen; drainage may be needed for worsening effusions or abscesses. 1

NOT Indicated (Do Not Use Routinely)

Tuberculous Pleural Effusion

• No evidence supports routine use of corticosteroids in pleural TB. 3, 6
• While steroids decrease pleural thickening, the clinical significance is unclear and does not justify routine use. 7
• Consider only if significant systemic symptoms (high fever) or particularly large effusion. 6

Uncomplicated Pulmonary TB

• No controlled trials in the modern drug era support routine corticosteroid use. 6, 8
• Steroids may improve symptoms rapidly but offer no long-term benefit. 8

Abdominal/Peritoneal TB

• Insufficient data to recommend adjunctive corticosteroids. 1
• A small study showed trend toward fewer fibrotic complications but was not statistically significant. 1

Genitourinary TB

• Efficacy of steroids for ureteric stenosis is unclear; not routinely recommended. 1

Critical Caveats and Monitoring

Drug Interactions and Precautions

• Corticosteroids are used in conjunction with appropriate anti-TB regimen, never as monotherapy. 9
• Monitor for hyperglycemia, gastrointestinal bleeding, invasive bacterial infections, and liver dysfunction. 3, 5
• Monitor liver function given hepatotoxic potential of concurrent anti-TB medications. 2
• Corticosteroids may mask signs of infection and increase susceptibility to opportunistic infections. 9

HIV-Positive Patients

• The mortality benefit of steroids in TB meningitis appears preserved in HIV-positive patients, though data are limited (only 98 HIV+ participants in trials). 5
• Corticosteroids are generally recommended for TB meningitis in HIV co-infected patients despite limited specific evidence. 7

Duration of Anti-TB Therapy with Steroids

• TB meningitis: 9-12 months total (2 months INH/RIF/PZA/EMB, then 7-10 months INH/RIF). 1, 4
• Monitor with repeated lumbar punctures to assess CSF cell count, glucose, and protein, especially early in therapy. 1, 4
• TB spine: Standard 6-month regimen unless complicated. 2