Tuberculosis corticosteroids

Those at risk of developing tuberculosis (eg, those with Hodgkin s disease, severe diabetes mellitus, leukemia, and other serious illnesses and those receiving corticosteroids or drug therapy for a malignancy)... 

Etanercept (Enbrel) 25 mg twice weekly or 50 mg once weekly SC injection 1 -4 weeks ISR Monitor for infection ISR—topical corticosteroids, antipruritics, analgesics, rotate injection sites Screen for tuberculosis... 

Infections Corticosteroids may mask signs of infection, and new infections may appear during their use. There may be decreased resistance and inability of the host defense mechanisms to prevent dissemination of the infection. Restrict use in active tuberculosis to cases of fulminating or disseminated disease in which the corticosteroid is used for disease management with appropriate chemotherapy. Corticosteroids may exacerbate systemic fungal infections and may activate latent amebiasis. 

Serious adverse events occur in up to 6% of patients with anti-TNF therapy. The most important adverse effect of these drugs is infection due to suppression of the ThI inflammatory response. This may lead to serious infections such as bacterial sepsis, tuberculosis, invasive fungal organisms, reactivation of hepatitis B, listeriosis, and other opportunistic infections. Reactivation of latent tuberculosis, with dissemination, has occurred. Before administering anti-TNF therapy, all patients must undergo purified protein derivative (PPD) testing prophylactic therapy for tuberculosis is warranted for patients with positive test results. More common but usually less serious infections include upper respiratory infections (sinusitis, bronchitis, and pneumonia) and cellulitis. The risk of serious infections is increased markedly in patients taking concomitant corticosteroids. 

The British Thoracic and Tuberculosis Association. Inhaled corticosteroids compared with oral prednisone in patients starting long-term corticosteroid therapy for asthma. Lancet 1975 2(7933) 469-73. 

Adrenal steroid and tuberculosis. In pulmonary tuberculosis a corticosteroid may be given to severely ill patients. It reduces the injurious reaction of the body to tuberculoprotein and buys time for the chemotherapy to take effect. It also causes the patient to feel better much more quickly. In the absence of effective chemotherapy, an adrenal steroid will cause tuberculosis to extend and it should never be used alone, e.g. for another disease, if tuberculosis is suspected. 

Contraindications to the use of adrenal steroids for suppressing inflammation are all relative, depending on the advantage to be expected. They should be used only for serious reasons if the patient has diabetes, a history of mental disorder or peptic ulcer, epilepsy, tuberculosis, hypertension or heart failure. The presence of any infection demands that effective chemotherapy be begun before the steroid, but there are exceptions (some viral infections, see above). Topical corticosteroid applied to an inflamed eye (with the very best of intention) can be disastrous if the inflammation is due to herpes virus. 

Morris H, Muckerjee J, Akhtar S, Abdullahi L, Harrison M, Scott G. Use of corticosteroids to suppress drug toxicity in compheated tuberculosis. J Infect 1999 39(3) 237-40. 

In addition to pituitary-adrenal suppression, prolonged therapy with corticosteroids can cause fluid and electrolyte disturbances, hypertension, hyperglycemia, and glycosuria. It also increases the susceptibility to infections including tuberculosis causes... 

Alzeer AH, FitzGerald JM. Corticosteroids and tuberculosis risks and use as adjunct therapy (see comments). Tubercle Lung Dis 1993 74 6-11. 

Duration of therapy for extrapulmonary tuberculosis caused by drug-resistant organisms is not known. Corticosteroid preparations vary among studies. 

Anti-inflammatory corticosteroids depress the immune system. Response to infection can be severely impaired as a result of inhibition of the activity of leukocytes and reduction in their numbers. Infections such as tuberculosis can spread extensively before they are discovered. 

Fomierly, adrenal gland destruction was often due to tuberculosis autoimmune disease is now the main cause of primary adrenal failure. Both cortisol and itldosterone production may be affected. Secondary failure to produce cortisol is more common. Frequently, this is due to long-standing suppression and subsequent impairment of the hypothalamic-pituitary-adrenocortical axis from therapeutic administration of corticosteroids. The causes of adrenal insufficiency are summarized in Figure 2. 

In a retrospective study of rheumatoid arthrihs pahents treated with leflunomide risk factors of severe infections were identified. Among the 401 patients that started on leflxmomide therapy, 8.2% developed severe infections (pneumonia, oral candidiasis, pyelonephrihs, pulmonary tuberculosis, cellulitis, disseminated herpes zoster, tonsil-lihs and pulmonary cryptococcosis). Risk factors for severe infections were older age, presence of diabetes mellitus and (increasing) daily dosage of corticosteroids [Sl ]. 

Mycobacterial Infections Several recent studies assessed the risk of mycobacterial infections in patients receiving ICS. A nested case-control study from the Korean national claims database identified 4139 patients who developed tuberculosis after initiation of an inhaled respiratory medication and 20,583 controls when matched for age, sex, diagnosis and the date of inhaler use initiation [12 ]. ICS was foxmd to be dose dependently (P < 0.001) associated with an increased rate of diagnosis with tuberculosis (adjusted OR = 1.20,95% Cl = 1.08,1.34). While use of oral corticosteroids increased the risk of tuberculosis (adjusted OR = 1.83,95% Cl = 1.58,2.12), it was foxmd to be a significant effect modifier of the association between ICS use and tuberculosis (TB) development (interaction P = 0.02). In those that used oral corticosteroids, ICS did not increase the risk of developing TB (adjusted OR = 1.35 95% C3 = 0.86,2.12). However, in those that did not use oral corticosteroids, ICS use slightly increased the risk of developing TB (adjusted OR = 1.17 95% Cl = 1.03,1.33). 

COPD sometimes occurs concomitantly with other disorders, such as scoliosis, fibrosis, or post-tuberculosis sequelae. A short course of corticosteroids can still be useful during acute infective exacerbations with prompt tapering as recovery occurs. 

Antibacterial agent used in treatment of tuberculosis and leprosy. Reagent for spectrophotometric anal, of corticosteroids. 

A patient with Addison s disease in whom the plasma half-life of cortisone was considerably reduced, requiring increased corticosteroid dosage, was described by Edwards et al. (34 ). Cortisone production rates in 4 patients with active pulmonary tuberculosis under treatment with rifampicin were also found to be greatly increased, the mean rate rising from 14.4 to 23.0 mg per 24 hours. It was postulated that these effects were the result of hepatic enzyme induction by rifampicin. 

Tuberculosis Although it is well established that aggravation or reactivation of tuberculosis may take place during corticosteroid therapy, a recent study in 132 patients representing 620 corticosteroid-years of therapy was not able to demonstrate evidence of active tuberculosis in any of these patients (122 ). The authors, and a subsequent editorial comment (13), find no indication for prophylactic antituberculosis therapy in corticosteroid-treated asthmatic patients. 

British medical Journal (1976) Tuberculosis in corticosteroid-treated asthmatics (Editorial). 2, 266. 

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