Corticosteroids for managing tuberculous meningitis

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Prasad K, Singh MB, Ryan H. Corticosteroids for managing tuberculous meningitis. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD002244. DOI: 10.1002/14651858.CD002244.pub4.
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The Cochrane Infectious Diseases Group (CIDG) have published an updated review to evaluate the effects of corticosteroids being used alongside anti-tuberculosis medication to treat people suffering from tuberculous meningitis.

Tuberculous meningitis is a serious form of tuberculosis (TB) that affects the meninges that cover a person's brain and spinal cord. It is associated with high death rates and with disability in people who survive. Corticosteroids have been used as an adjunct to antituberculous drugs to treat people with tuberculous meningitis, but their role has been controversial.

Corticosteroids help reduce inflammation in the brain and surrounding blood vessels, which reduces pressure on the brain and the number of deaths. However, there is some concern among clinicians that while corticosteroids may improve survival, survivors are more likely to be severely disabled.

The review author team, from the All India Institute of Medical Sciences, New Delhi and LSTM, examined all data published up to 18 March 2016. They included nine trials, with 1337 people in total, which evaluated the effect of giving dexamethasone, methylprednisolone, or prednisolone along with anti-tuberculosis drugs. One included trial was of high quality while all other included trials had inconsistencies due to incomplete reporting.

The review authors found that corticosteroids reduce the risk of death by a quarter at two months to two years after the start of treatment. One trial followed up all of the participants for five years, by which time there was no difference in the effect on death between the groups given the corticosteroids and those that weren't; however the reasons for this change over time is unknown.

Only one trial evaluated the effects of corticosteroids in human immunodeficiency virus (HIV)-positive people but the number is small that the review authors are not sure if the benefits in terms of fewer deaths are preserved in this group of patients.

The authors conclude that Corticosteroids reduce mortality from tuberculous meningitis, at least in the short term. Corticosteroids may have no effect on the number of people who survive tuberculous meningitis with disabling neurological deficit, but this outcome is less common than death, and the CI for the relative effect includes possible harm. However, this small possible harm is unlikely to be quantitatively important when compared to the reduction in mortality.

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