Adjunctive corticosteroid therapy in tuberculosis management

1. ADJUNCTIVE
CORTICOSTEROID
THERAPY IN
TUBERCULOSIS
MANAGEMENT

2. INTRODUCTION
The effectiveness of corticosteroids against
M.Tuberculosis was studied earlier in animal
models of tuberculosis & it was found that in
those animals who didn’t receive any specific
antituberculous therapy, the virulence of
M.tuberculosis was enhanced markedly by
corticosteroid administration.
Corticosteroids when used in conjuction with
effective antitubercular therapy has been
benefecial in milliary tuberculosis, tuberculous
meningitis, tuberculous pericarditis.

3.  Corticosteroids improve the outcome in
tuberculosis by suppressing the host mediated
inflammation.
 Adjunctive corticosteroid therapy may be life
saving in patients with miliary tuberculosis, is
little doubtful.
 It has been appreciated that steroid therapy
given to patients with untreated or
unrecognized tuberculosis results in
overwhelming disease and death.
 Eleanor Roosevelt died of undiagnosed miliary
tuberculosis while being treated with steroid for
what was thought to be sarcoidosis.

4. When to use steroids in
tuberculosisDefinite indications:
 CNS tuberculosis
 Pericardial tuberculosis
 Adrenal insufficiency
Other reasonable indications:
 IRIS/Paradoxical response
 Far advanced pulmonary TB with severe systemic and
respiratory morbidity
 Severe cutaneous hypersensitivity reactions to anti-TB
drugs
 Persistent fever even after 3-4 weeks of T/t
 Bronchial obstruction
 Miliary TB with toxemia

5. Other indications:
 BCG scar keloid
 Sick/elderly/extensive primary TB with
large pleural effusion
 Tubercular pneumonia with acute
respiratory failure
 Tubercular sarcoidosis
 Lymph node TB
 ? Laryngeal TB
 ? Genitourinary TB
 ? TB in HIV positive patients

6. Steroids for TBM
Corticosteroids improve outcome as these:
• Decrease inflammation, especially in the
subarachnoid space.
• Reduce cerebral and spinal cord edema
• Reduce inflammation of small bllod
vessels and therefore reduce damage
from blood flow slowing to the underlying
brain tissue.

7. Corticosteroids therapy based upon
urgent warning signs:
Patients who are progressing from one
stage to the next at or before the
introduction of chemotherapy, especially if
associated with any of the conditions –
a. Patients with acute “encephalitis”
presentation, especially if the CSF
opening pressure is > 400 mmH2O or if
there is clinical or CT evidence of
cerebral edema.
b. Exacerbation of clinical signs (eg. Fever,
change in mentation) after beginning
ATT.

8. c. spinal block or incipient block ( CSF
proein >500 mg/dl and rising )
d. Head CT evidence of marked basillar
enhancement or moderate or advancing
hydrocephalus
e. Patients with intracerebral tuberculoma,
where edema is out of proportion to the
mass effect and there are any clinical
neurologic signs.

9. Recommended dosage regimen
of corticosteroid in TBM
 Stage 1
GCS score – 15,
no focal
neurological deficit
 Total duration – 6 wks
Inj. Dexamethasone
.3mg/kg i.v. day1-7;
.2mg/kg day8-14; .1mg/kg
day15-21 f/b tab.
Dexamethasone
3mg/day orally days 22-28
2mg/day orally days 29-35
1mg/kg orally days 36-42

10.  Stage 2&3
Stage 2 – GCS-11-
14; or focal
neurological deficit
present
Stage 3 – GCS <11
 Total duration 8wks
Inj.dexamethasone
.4mg/kg i.v. day 1-7;
.3mg/kg day 8-14 , .2
mg/kg day 15-21;
.1mg/kg day 22-28 f/b
tab. Dexamethasone
4mg/day orally days 29-
35
3mg/day orally days 36-
42

11. Steriod in pericardial TB
 In early stages of pericardial TB
corticosteroid therapy decreases fluid
accumulation, decrease need for
procedure and even in late stage
improve symptomatic & hemodynamic
recovery.
 In a study : active effusive TB
pericarditis the mortality rate was 3%
vs 14% & reduced need for reduced
need for repeated pericardiocentesis
7of 76 vs 17 of 74.

12. Steroids for pulmonary TB
The summary of 11 RCTs of steroids use in
PTB is:
 Clinical condition improve more rapidaly
(effects more pronounced in severely ill)
 Absence of long term benefecial effect
 Faster radiological response
 Minority of patient may have rebound if
steroid discontinued too abruptly.
 Steroids administration in the face of
inadequate ATT appears harmfull to
patients.

13. Steroids in pleural TB
 Corticosteroids in pleural TB reduces
the fibrotic sequele, early resolution of
clinical symptoms & signs.
 Steroids in pleural TB are reserved for
patients with large effusions,
dyspnoea &/or disabling chest pain
and elder patient.
 Benefits are more palliative and
temporary and systemic steroids are
superior to local steroids.

14. Steroids in HIV-TB disease
 Significant decrease in generalized
lymphadenopathy and cough at 2
months but undesirable increase in
H.zoster and Kaposi sarcoma.
 There was no difference in survival at
1 year.
 Data do not support use of steroids in
reducing morbidity and mortality due
to TB directly or influencing survival
due to slowing of HIV progression.

15. Steroids in milliary TB
 Study from China in 1981 suggest non
significant trend toward better
outcome in steroid group than for
controls.
 Available data suggest a lack of effect
of steroid on acute milliary TB &
severely ill patient needs.

16. Adesonian crisis during ATT
 some patients of post-primary TB may
have true addison disease; stress of
infection & use of ‘rifampicin’ may
cause adrenal failure.

17. Steroid in endobronchial obstruction
 Steroids causes reduction in bronchial
compression; favourable response in
radiographic & bronchoscopic
appearance.
 Use depends upon degree, site &
nature of obstruction.

18. Steroids in lymph node TB
 One third nodes involved in tubercular
peripheral lymphadenopathy ‘flare’
with an exacerbation of pain &
swelling after starting ATT.
 Intralesional/Intralymphnodal depot
steroid therapy may be benefecial in
Hilar/mediastinal lymphadenopathy
with pressure symptoms.

19. Steroids in laryngeal TB
 Laryngeal TB usually responds to
voice rest & ATT.
 Short course prednisolone may be use
in severe pain.
 There are lack of datas to support
their use.

20. Steroids in ATT induced fever
 Drug fever is not uncommon with use
of ATT.
 Fever is usually due to INH or
Rifampicin.
 Patients usually presents with fever,
increase transaminases level &
relative bradycardia.
 Serial ESR measurement important.
 ATT induced fever promptly responds
to prednisolone.

21. Steroids in cutaneous hypersensitivity to
drugs
 Anti-TB drugs can cause SJ syndrome &
TEN, severe reaction may require
systemic steroids.