Corticosteroids for managing tuberculous meningitis
Kameshwar Prasad1, Mamta B Singh1, Hannah Ryan2
1. All India Institute of Medical Sciences, Department of Neurology, New Delhi, India
2. Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, UK
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.
What is tuberculous meningitis and how might corticosteroids work?
Tuberculous meningitis is a serious form of tuberculosis that affects the meninges that cover the brain and spinal cord, causing headache, coma and death. The clinical outcome is often poor even when people with tuberculous meningitis are treated with antituberculous drugs.
Corticosteroids are commonly used in addition to antituberculous drugs for treating people with the condition. These drugs help reduce inflammation of the surface of the brain and associated blood vessels, and are thought to decrease pressure inside the brain, and thus reduce the risk of death. Some clinicians are concerned that corticosteroids may improve survival, but result in more severely disabled survivors.
What the evidence shows
We examined the evidence published up to 18 March 2016 and included nine trials with 1337 people that evaluated either dexamethasone, methylprednisolone, or prednisolone given in addition to antituberculous drugs; one trial was of high quality, while the other trials had uncertainties over study quality due to incomplete reporting.
The analysis shows that corticosteroids reduce the risk of death by a quarter at two months to two years after treatment was started (high quality evidence). Corticosteroids make little or no difference to the number of people who survive TB meningitis with brain damage causing disability (low quality evidence); because this event is uncommon, even taking the most pessimistic estimate from the analysis of a slight increased risk with corticosteroids means this would not be quantitatively important when compared to the reduction in deaths.
One trial followed up participants for five years, by which time there was no difference in the effect on death between the two groups, although the reason 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 so we are not sure if the benefits in terms of fewer deaths are preserved in this group of patients.