8.2 Use of corticosteroids

Corticosteroids have been used to support the treatment of serious and severe consequences of TB, such as miliary TB, respiratory insufficiency, CNS involvement and pericarditis.

The WHO Guidelines for treatment of drug-susceptible TB and patient care 2017 update made the following recommendations (2):

In patients with tuberculous meningitis, an initial adjuvant corticosteroid therapy with dexamethasone or prednisolone tapered over 6–8 weeks should be used.

(Strong recommendation, moderate certainty in the evidence)

In patients with tuberculous pericarditis, an initial adjuvant corticosteroid therapy may be used.

(Conditional recommendation, very low certainty in the evidence)

The recommendations are limited to these two forms of extrapulmonary TB. In patients with TB meningitis, evidence from RCTs (101–105) showed lower rates of death, severe disability and relapse when patients received steroids with TB treatment. The mortality benefit increased with increasing severity of TB meningitis. Adverse events and severe adverse events, including severe hepatitis, were lower in the patients receiving steroids. In patients with TB pericarditis, studies showed a benefit to steroid treatment with regard to death, constrictive pericarditis and treatment adherence (106–113).

Although the evidence and the recommendations primarily relate to non-MDR-TB, there is no reason why these recommendations should not apply also to patients with MDR/RR-TB, on the condition that the patient is still receiving the TB treatment regimen. Corticosteroids are immunosuppressive and therefore can weaken the body’s response to fight TB; hence, they should only be used if clearly indicated and if the patient is on an adequate effective regimen. If corticosteroids are used in an inadequate regimen, this could accelerate the patient’s deterioration. Oral treatment can be given, but when a more immediate response is needed injectable corticosteroids are often used initially.

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