Glucocorticoids adjuvant therapy for tuberculosis, see the latest expert consensus!

There is an irrational phenomenon in the clinical use of glucocorticoids (GCs) for the adjuvant treatment of tuberculosis, and the "Expert Consensus on the Rational Application of Glucocorticoids in tuberculosis Treatment" mainly puts forward 22 recommendations for the adjuvant treatment of tuberculosis with GCs, in order to better guide the standardized application of GCs.

A list of key recommendations

Recommendation 1: For those with short course, mild disease, no serious comorbidities, and body temperature below 39.0 ° C, the initial dose is 10 mg of dexamethasone, 1 time / day, and the course of treatment is controlled as much as possible at 1 month; for those with a long course of disease, severe disease, many comorbidities, and a body temperature of more than 39.0 ° C, especially those with impaired consciousness, the initial dose is 0.3 to 0.4 mg / kg dexamethasone, 1 time / day. To control fever and improve symptoms, a gradual reduction method is taken, and the subsequent dose is reduced according to consciousness, body temperature, cerebrospinal fluid protein and intracranial pressure, and the course of treatment is controlled as much as possible for 1 to 2 months. (High-level evidence, strong recommendation)

Recommendation 2: Prednisone (or the equivalent dose of methylprednisolone) is commonly used in children with tuberculous meningitis 1.5 to 2 mg·kg-1·d-1, the maximum dose is 45 mg/day, and the total course of treatment is generally 8 to 12 weeks after symptom control. (Intermediate evidence, strong recommendation)

Recommendation 3: CSF protein is significantly increased, > 3.0 g / L, can be added to the intrathecal injection, generally dexamethasone 2 mg / time and isoniazid 100 mg / time, 1 to 2 times / week, the course of treatment depends on the improvement of CSF protein and intracranial pressure, when cerebrospinal fluid protein

Recommendation 4: During the acute exudation phase of tuberculous pericarditis, prednisone 20 to 30 mg/day orally, once a day, the pericardial effusion disappears or the thickness of the effusion is less than 5 mm, and the body temperature is normal, a small dose reduction method can be used, once a week, 5 mg each time, and the total course of treatment should not exceed 6 weeks. (High-level evidence, strong recommendation)

Recommendation 5: GCs are not recommended for patients with effusions of less than 5 mm in effusion-constriction and constrictive tuberculous pericarditis chronic. (High-level evidence, strong recommendation)

Recommendation 6: GCs should be added promptly during the exudation phase of tuberculous pericarditis in children, and the total course of treatment is generally 3 to 4 weeks. (Intermediate evidence, strong recommendation)

Recommendation 7: Pleural effusion in the acute exudation stage, tuberculosis poisoning symptoms are obvious, imaging suggests that the pleural effusion grows rapidly, the dose of prednisone is 20 to 30 mg / day, after the body temperature is normal, a small dose reduction method can be used, 1 to 2 times a week, 5 mg each time, the total course of treatment should not exceed 4 weeks. (Intermediate evidence, strong recommendation)

Recommendation 8: GCs are not recommended in patients with chronic tuberculous pleurisy with extensive hypertrophic adhesions to the pleura. (High-level evidence, strong recommendation)

Recommendation 9: Patients with mixed tuberculous pleurisy with pleural hypertrophy with pleural effusion are chronic and should not be treated with GCs. (High-level evidence, strong recommendation)

Recommendation 10: For children with tuberculous pleurisy, the amount of pleural effusion above moderate, tuberculous polyserous effusion, prednisone 1 mg ·kg-1·d-1, the maximum dose is 45 mg/day, the dose is reduced after 1 to 2 weeks, and the total course of treatment is generally 4 to 6 weeks. (Intermediate evidence, strong recommendation)

Recommendation 11: Exudative tuberculous peritonitis after systemic anti-tuberculosis treatment and active withdrawal of fluid, the symptoms of tuberculosis poisoning such as hyperthermia are not alleviated, and prednisone 20 to 30 mg/day can be added when the function of important organs is endangered, and after the body temperature is normal, a small dose reduction method can be used, once a week, 5 mg each time, and the total course of treatment should not exceed 6 weeks. (Intermediate evidence, strong recommendation)

Recommendation 12: The use of GCs in adhesive tuberculous peritonitis may lead to intestinal perforation or mesenteric lymph node tuberculosis rupture, causing diffuse peritonitis, so it is not recommended. (High-level evidence, strong recommendation)

Recommendation 13: Hormones are contraindicated in caseless tuberculosis peritonitis. (High-level evidence, strong recommendation)

Recommendation 14: After systemic anti-tuberculosis therapy, there is no relief of symptoms of tuberculosis poisoning such as hyperthermia, and/or when symptoms of high cranial pressure such as headache, nausea, vomiting, etc., methylprednisolone can be added, starting at 24 mg each time, once a day, intravenous infusion, according to body temperature, other vital signs and absorption of lung lesions, the dose is gradually reduced, and the total course of treatment is usually not more than 8 weeks. If tuberculous meningitis is complicated by tuberculous meningitis, refer to the Tuberculous Meningitis Recommendation. (Intermediate evidence, strong recommendation)

Recommendation 15: Intravenous GCs may be given when symptoms of toxicity are apparent. Generally, dexamethasone 10 mg (or equivalent dose of methylprednisolone) is selected once / day, after the symptoms of poisoning and the absorption of lung lesions, the dose is reduced once every 710 days, and according to the symptoms and radiographic improvement, it is changed to prednisone or methylprednisolone orally, and the dose is gradually reduced until the end of the reduction, and the total course of treatment is usually not more than 6 weeks. (Intermediate evidence, weak recommendation)

Recommendation 16: On the basis of regular anti-tuberculosis chemotherapy, oral prednisone 20 to 30 mg/day, according to the patient's eye inflammation regression gradually decreased, 1 to 2 times a week, 5 mg each time, the total course of treatment is usually not more than 6 weeks. (Intermediate evidence, strong recommendation)

Recommendation 17: Anterior uveitis can be used topically with GCs eye drops. Acute phase: 1% prednisolone acetate or 0.1% dexamethasone, starting with a high point eye frequency, and gradually decreasing after inflammation control. The convalescent period is used with 0.1% flumethasolone, and the frequency of point eyes should be gradually decreased. Long-term use should monitor intraocular pressure and lens opacification; patients with tuberculous uveitis with macular edema receive peribulular injection of GCs, which can significantly reduce macular edema and improve vision. Methylprednisolone 40 mg/ml is recommended for 12 to 36 hours, and discontinuation may be considered for poor treatment. (Intermediate evidence, weak recommendation)

Recommendation 18: Aerosolized inhaled GCs are used as an adjunct to acute inflammatory infiltration of laryngeal tuberculosis, which can reduce congestion and edema and relieve symptoms. (Intermediate evidence, weak recommendation)

Recommendation 19: Mild to moderate drug eruptions can be given prednisone 40 to 60 mg/day, severe drug eruptions can be used to methylprednisolone 80 to 120 mg /day, continuous use for 3 to 5 days, according to the severity of tuberculosis, reduce the dose as appropriate, can be reduced to discontinuation within 2 to 4 weeks; anaphylactic shock should be used in impact doses, generally dexamethasone 10 to 20 mg (other intravenous GCs are converted according to the corresponding dose of dexamethasone), which can be rapidly reduced according to the condition. (High-level evidence, strong recommendation)

Recommendation 20: The dosage and duration of GCs refer to the relevant consensus, guidelines or routes of each disease. (High-level evidence, strong recommendation)

Recommendation 21: The use of GCs in the above conditions is at risk of aggravation and deterioration, and the use of GCs is not recommended. (High-level evidence, strong recommendation)

Recommendation 22: For diseases that must be controlled with GCs, if the above conditions are combined, GCs can be used with caution while actively treating the primary disease and closely monitoring the above changes in the condition. (Intermediate evidence, weak recommendation)

The above content is excerpted from: Tuberculosis Medical Department of the Eighth Medical Center of the General Hospital of the Chinese People's Liberation Army/ Tuberculosis Research Institute of the Whole Army/ Key Laboratory of Tuberculosis Prevention and Treatment of the Whole Army/ Beijing Key Laboratory of Tuberculosis Diagnosis and Treatment New Technology, Editorial Board of Chinese Journal of Tuberculosis Prevention. Expert consensus on the rational application of glucocorticoids in tuberculosis treatment[J]. China Journal of Antituberculosis,2022,44(1):28-37.