Interventions for Tuberculosis Control and Elimination 2002
Interventions for Tuberculosis Control and Elimination 2002
Interventions for Tuberculosis Control and Elimination 2002
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Appendix 1<br />
Adjunctive treatment<br />
Adjunctive therapy with corticosteroids<br />
The role of corticosteroids in the treatment of tuberculosis is not precisely<br />
known <strong>and</strong> the opinion concerning their use in different clinical situations<br />
is often somewhat controversial. The available evidence <strong>for</strong> <strong>and</strong> against<br />
their use is reviewed here, following the extensive review by Dooley et<br />
al., 908 supplemented by additional reports.<br />
Pulmonary tuberculosis<br />
The value of corticosteroids in the treatment of pulmonary tuberculosis has<br />
been evaluated in several controlled trials. 909-920<br />
Sputum conversion was not affected by corticosteroid therapy in any<br />
of these studies; early sputum conversion was faster in the control group<br />
in one study <strong>and</strong> faster in the corticosteroid group in another.<br />
On the other h<strong>and</strong>, clinical <strong>and</strong> radiologic improvement was generally<br />
more rapid in the corticosteroid treated group, particularly among the more<br />
seriously ill patients. In the United States Public Health Service trial, prednisolone<br />
produced more frequent <strong>and</strong> more rapid radiologic clearing of the<br />
infiltrate in black patients, but was of no benefit in white patients. 918<br />
In the five-year follow up of the United States Veterans Administration<br />
study, patients treated with corticosteroids were less likely to have died due<br />
to relapse of their tuberculosis, or due to respiratory illnesses such as bronchitis,<br />
respiratory insufficiency, or pneumonia. 917<br />
A controlled clinical trial from India 920 is significant in two ways.<br />
First, it is the only study using corticosteroids as adjunct therapy together<br />
with rifampicin-containing regimens. Second, it revealed that patients treated<br />
with corticosteroids who had strains initially resistant to isoniazid <strong>and</strong> streptomycin<br />
had a poorer bacteriologic response than those not treated with<br />
steroids. The deleterious effect of steroids in patients with sub-optimal<br />
chemotherapy had been observed earlier. 921 This had previously been shown<br />
in animal models as well, 922,923 <strong>and</strong> is not unexpected.<br />
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