7.3 Use of adjuvant steroids in the treatment of tuberculous meningitis and pericarditis

Treatment with corticosteroids is recommended for tuberculous meningitis and pericarditis because the benefits outweigh the potential harms of corticosteroid therapy (1, 23, 37, 43, 46).

In patients with tuberculous meningitis, evidence from RCTs (47-51) showed lower rates of mortality, death or severe disability, and disease relapse when patients were treated with steroids in addition to anti-TB treatment. The mortality benefit increased with the increasing severity of disease. Additionally, rates of adverse events and severe adverse events, including severe hepatitis, were lower in patients receiving steroids; hence, steroids should be given regardless of the severity of meningitis.

In patients with tuberculous pericarditis, a systematic review (52-59) found a benefit to steroid treatment in relation to death, constrictive pericarditis and treatment adherence. When the studies were considered individually, the largest (1400 patients) and most recent study – the Investigation of the Management of Pericarditis (IMPI) study – showed no benefit of steroids (54). However, a factor complicating these findings is HIV infection. In the IMPI study, 67% of subjects were HIV-positive and only 14% were on ART. This raises the question as to whether immunosuppressed patients may have had a different benefit from steroids when compared with HIV-negative people or PLHIV who are on ART. In the IMPI study, a supplemental analysis of only HIV-negative patients showed a small mortality benefit with steroid treatment. However, another smaller study of 58 subjects, all of whom were HIV-positive, found that steroids reduced mortality (55). Other studies in the review did not address HIV and mortality.

With regard to the use of steroids in tuberculous pericarditis, in one study, an increase in HIV-related cancers (non-Hodgkin’s lymphoma and Kaposi sarcoma) was observed (54). However, this increase appeared to be caused by co-administration of immunotherapy (M. indicus pranii). The increase in cancers was not confirmed in another study (38). Practitioners should evaluate when intravenous steroids are necessary, and when oral formulations may be equally effective.

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