Corticosteroids for tuberculous pleurisy
Abstract
Background
Corticosteroids used in addition to antituberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are inconsistent, raising doubt as to whether such treatment is worthwhile. Concern also exists regarding the potential adverse effects of corticosteroids, especially in HIV‐positive people.
Objectives
To evaluate the effects of adding corticosteroids to drug regimens for tuberculous pleural effusion.
Search methods
In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, Current Controlled Trials, and reference lists of articles.
Selection criteria
Randomized and quasi‐randomized controlled trials comparing any corticosteroid with no treatment, placebo, or other active treatment (both groups should receive the same antituberculous drug regimen) in people diagnosed with tuberculous pleurisy.
Data collection and analysis
Two authors independently assessed trial methodological quality and extracted data. Data were analysed using relative risks (RR) and mean difference (MD) with 95% confidence intervals (CI). The fixed‐effect model was applied in the absence of statistically significant heterogeneity.
Main results
Six trials with 633 participants met the inclusion criteria; one trial included only HIV‐positive people. Compared to control, corticosteroid use was associated with less residual pleural fluid at four weeks (RR 0.76, 95% CI 0.62 to 0.94; 394 participants, 3 trials) and reduced pleural thickening (RR 0.69, 95% CI 0.51 to 0.94; 309 participants, 4 trials). We found no evidence of an effect of corticosteroids on death from any cause (194 participants, 1 trial), respiratory function (191 participants, 2 trials), residual pleural fluid at eight weeks (399 participants, 4 trials), or pleural adhesions (123 participants, 2 trials). Although discontinuation of treatment due to adverse events was more frequent in participants receiving corticosteroids than placebo (RR 2.80, 95% CI 1.12 to 6.98; 586 participants, 6 trials), the effects were generally mild. The risk of Kaposi sarcoma may be increased in HIV‐positive people receiving corticosteroids (RR 13.00, 95% CI 0.74 to 227.63; 194 participants, 1 trial).
Authors' conclusions
There are insufficient data to support evidence‐based recommendations regarding the use of adjunctive corticosteroids in people with tuberculous pleurisy. Randomized controlled trials that are sufficiently powered to evaluate the effects of corticosteroids on both morbidity and mortality are needed. The effects of corticosteroids on HIV‐related complications, such as Kaposi sarcoma, should be assessed in people co‐infected with HIV.
PICOs
Plain language summary
No clear evidence that corticosteroids are effective for tuberculous
Tuberculous pleural effusion results from tuberculous infection of the membrane covering of the lungs. This results in a build up of fluid around the lung that impairs breathing and may lead to restriction of lung function in the long term. Some clinicians believe that corticosteroids used in combination with antituberculous drugs can help to prevent these complications. We found no clear evidence supporting the use of corticosteroids in people with tuberculous pleural effusion, regardless of HIV status. However, only one trial evaluated the balance between benefit and harm of corticosteroids in people infected with HIV.
