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Meta-Analysis
. 2014 Nov 12;2014(11):CD011370.
doi: 10.1002/14651858.CD011370.

Adjunctive steroid therapy for managing pulmonary tuberculosis

Julia A Critchley  1 , Lois C Orton, Fiona Pearson
Affiliations
Meta-Analysis

Adjunctive steroid therapy for managing pulmonary tuberculosis

Julia A Critchley et al. Cochrane Database Syst Rev. .

Abstract

Background: Tuberculosis causes approximately 8.6 million disease episodes and 1.3 million deaths worldwide per year. Although curable with standardized treatment, outcomes for some forms of tuberculosis are improved with adjunctive corticosteroid therapy. Whether corticosteroid therapy would be beneficial in treating people with pulmonary tuberculosis is unclear.

Objectives: To evaluate whether adjunctive corticosteroid therapy reduces mortality, accelerates clinical recovery or accelerates microbiological recovery in people with pulmonary tuberculosis.

Search methods: We identified studies indexed from 1966 up to May 2014 by searching: Cochrane Infectious Diseases Group's trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and LILACS using comparative search terms. We handsearched reference lists of all identified studies and previous reviews and contacted relevant researchers, organizations and companies to identify grey literature.

Selection criteria: Randomized controlled trials and quasi-randomized control trials of recognized antimicrobial combination regimens and corticosteroid therapy of any dose or duration compared with either no corticosteroid therapy or placebo in people with pulmonary tuberculosis were included.

Data collection and analysis: At least two investigators independently assessed trial quality and collected data using pre-specified data extraction forms. Findings were reported as narrative or within tables. If appropriate, Mantel-Haenszel meta-analyses models were used to calculate risk ratios.

Main results: We identified 18 trials, including 3816 participants, that met inclusion criteria. When compared to taking placebo or no steroid, corticosteroid use was not shown to to reduce all-cause mortality, or result in higher sputum conversion at 2 months or at 6 months (mortality: RR 0.77, 95%CI 0.51 to 1.15, 3815 participants, 18 studies, low quality evidence; sputum conversion at 2 months RR 1.03, 95%CI 0.97 to 1.09, 2750 participants, 12 studies; at 6 months; RR1.01, 95%CI 1.01, 95%CI 0.98 to 1.04, 2150 participants, 9 studies, both low quality evidence). However, corticosteroid use was found to increase weight gain (data not pooled, eight trials, 1203 participants, low quality evidence), decrease length of hospital stay (data not pooled, three trials, participants 379, very low quality of evidence) and increase clinical improvement within one month (RR 1.16, 95% CI 1.09 to 1.24; five trials, 497 participants, low quality evidence).

Authors' conclusions: It is unlikely that adjunctive corticosteroid treatment provides major benefits for people with pulmonary tuberculosis. Short term clinical benefits found did not appear to be maintained in the long term. However, evidence available to date is of low quality. In order to evaluate whether adjunctive corticosteroids reduce mortality, or accelerate clinical or microbiological recovery in people with pulmonary tuberculosis further large randomized control trials sufficiently powered to detect changes in such outcomes are needed.

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Conflict of interest statement

No known conflicts of interest.

Figures

1
1
Risk of bias summary: review authors' judgements regarding each risk of bias item for each included study.
2
2
Funnel plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.2 Sputum conversion by 2 months.
3
3
Funnel plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.6 Clinical Improvement at 1 month.
4
4
Forest plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.1 All‐cause mortality.
5
5
Forest plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.2 Sputum conversion by 2 months.
6
6
Forest plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.3 Sputum conversion at 6 months.
7
7
Forest plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.4 Treatment Failure.
8
8
Forest plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.5 Relapse.
9
9
Forest plot of comparison: 1 Steroid therapy comparative to either no therapy or placebo, outcome: 1.6 Clinical Improvement at 1 month.
1.1
1.1. Analysis
Comparison 1 Steroid therapy comparative to either no therapy or placebo, Outcome 1 All‐cause mortality.
1.2
1.2. Analysis
Comparison 1 Steroid therapy comparative to either no therapy or placebo, Outcome 2 Sputum conversion by 2 months.
1.3
1.3. Analysis
Comparison 1 Steroid therapy comparative to either no therapy or placebo, Outcome 3 Sputum conversion at 6 months.
1.4
1.4. Analysis
Comparison 1 Steroid therapy comparative to either no therapy or placebo, Outcome 4 Treatment Failure.
1.5
1.5. Analysis
Comparison 1 Steroid therapy comparative to either no therapy or placebo, Outcome 5 Relapse.
1.6
1.6. Analysis
Comparison 1 Steroid therapy comparative to either no therapy or placebo, Outcome 6 Clinical Improvement at 1 month.
See this image and copyright information in PMC

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