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Evidence summaries

Steroids for Tuberculous Pleurisy

There is insufficient evidence to assess the effectiveness of corticosteroids on risk of death or improvement in lung function in participants with tuberculous pleural effusion, regardless of HIV status. Level of evidence: "D"

A Cochrane review [Abstract] 1 included 6 studies with a total of 590 subjects. Two trials were in HIV-negative people, one trial was in HIV-positive people, and three trials did not report HIV status. Corticosteroids may reduce the time to resolution of pleural effusion. Risk of residual pleural effusion on chest X-ray was reduced by 45% at eight weeks (RR 0.54, 95% CI 0.37 to 0.78; 237 participants, 2 trials, low certainty evidence), and 65% at 24 weeks (RR 0.35, 95% CI 0.18 to 0.66; 237 participants, 2 trials).

Compared with control, corticosteroids may reduce the risk of having pleural changes (such as pleural thickening or pleural adhesions), on chest X-ray at the end of follow-up by almost one third (RR 0.72, 95% CI 0.57 to 0.92; 393 participants, 5 trials,low certainty evidence), which translates to an absolute risk reduction of 16%.

One trial reported deaths in people that were HIV-positive, with no obvious difference between the groups; the trial authors' analysis suggests that the deaths observed in this trial were related to HIV disease rather than pleural TB (RR 0.91, 95% CI 0.64 to 1.31; 197 participants, 1 trial).

Limited data on long-term functional respiratory impairment was found on 187 people in two trials, which reported that average percentage predicted forced vital capacity was similar in the group receiving prednisolone and in the control group.The risk of adverse events that led to discontinuation of the trial drug was higher in people with pleural TB receiving corticosteroids (RR 2.78, 95% CI 1.11 to 6.94; 587 participants, 6 trials, low certainty evidence). The trial in HIV-positive people reported on six different HIV-related infections, with no obvious differences. However, cases of Kaposi's sarcoma were only seen in the corticosteroid group (with 6/99 cases in the steroid group compared to 0/98 in the control group).

Comment: The quality of evidence is downgraded by imprecise results (few patients and wide confidence intervals), indirectness (lack of data on clinically important outcomes) and by study quality (inadequate or unclear allocation concealment).

    References

    • Ryan H, Yoo J, Darsini P. Corticosteroids for tuberculous pleurisy. Cochrane Database Syst Rev 2017;(3):CD001876. [PubMed]

Primary/Secondary Keywords