HomeFor a more in-depth review of adjunctive therapies please see Chapter 7: Extra-pulmonary Tuberculosis. Corticosteroids are used as adjunctive therapy in select situations to prevent morbidity and mortality due to the inflammatory response. They are indicated for children with TB meningitis. In prospective, randomized trials they decreased mortality rates as well as neurologic and cognitive dysfunction.78 Dexamethasone 0.3 mg-0.4 mg/kg/day for the first week and then tapered over six weeks or prednisone 1-2 mg/kg/day (maximum 60 mg) for three weeks tapered over the next three weeks have been used in those older than 14 years of age.78,79 For children, the AAP and other experts have suggested that 2 mg/kg/day per day of prednisone (maximum 60 mg/day) or its equivalent for 4 to 6 weeks, and then tapered, is adequate.23,80 Higher prednisone doses (4 mg/kg/day then tapered over 4-6 weeks) have been evaluated and can be considered if increasing intracranial pressure continues.78 In selected cases of severe paradoxical reactions/immune reconstitution inflammatory syndrome (vision-threatening reactions), other immunomodulating, steroid-sparing agents, including infliximab, have been used.81 Expert consultation is advised in these instances.
The use of corticosteroids in pleural TB is not supported by current evidence. Based on expert opinion, corticosteroids may have a role in endobronchial disease to relieve obstruction and atelectasis.23 They may also be considered for children with pericardial effusions, severe miliary disease to mitigate alveolar-capillary block, and in the presence of severe immune reconstitution inflammatory syndrome reactions.82 Corticosteroids should only be used in conjunction with effective anti-TB therapy and then tapered slowly over several weeks to avoid a rebound reaction. Generally, in non-meningitic conditions, 1-2 mg/kg/day of prednisone (maximum 60 mg/day) or its equivalent is recommended and then tapered over 6 to 8 weeks.
While several reports suggest that a high proportion of children with TB disease and infection may have low vitamin D levels, vitamin D supplementation does not clearly affect treatment outcomes or prevent TB infection or disease.83–87 Existing recommendations regarding vitamin D supplementation for the population should be followed and additional supplementation should be considered in populations at increased risk of inadequate intake.88–90
Switch To: Français