Corticosteroids and tuberculosis: risks and use as adjunct therapy

Adjunct therapy with corticosteroids, in conjunction with antituberculous drugs, may be appropriate in particular forms of tuberculosis. Prospective controlled trials have shown a benefit in tuberculous meningitis, pericardial and pleural disease. Although benefit has been shown in pleural disease, adjunct therapy is not routinely required unless there are significant systemic symptoms of fever or a particularly large effusion. It has been recommended in the past that corticosteroids should be used routinely in endobronchial TB, especially pediatric disease, but our recent experience has been that such therapy is not usually required. Although corticosteroid therapy is sometimes recommended in extensive pulmonary disease there are no controlled trials, in the modern drug era, to support such therapy. Where adrenal suppression is a concern supplemental corticosteroids are indicated. Fever, be it drug-related or from systemic disease, sometimes requires suppression with corticosteroids. The usual dose required is 40-60 mg of prednisone orally daily for 4-6 weeks depending on the system involved, with tapering doses of prednisone subsequent to this. Local corticosteroid therapy of BCG-related keloid reactions may also be useful. Anecdotal reports suggest immune suppression with corticosteroids predisposes to tuberculosis but retrospective studies on patients taking, in general, low doses of prednisone have not confirmed this risk. Corticosteroid interaction with the oral birth control pill and rifampin need also to be accounted for in prescribing these agents.