Steroids May Help Reduce Deaths from All Types of Tuberculosis

The routine use of steroids to treat tuberculosis may help reduce deaths from all types of the disease, according to a new review of existing research.

Each year there are 8.7million cases of TB worldwide, and it causes 1.4million deaths. The most common form of the disease (pulmonary TB) affects the lungs, but there are many other forms and it can affect almost all the body's organs.

Currently, steroids are routinely used only for certain types of TB -- each of which affects a different organ system -- where they have been proven effective as a secondary treatment alongside anti-TB drugs. Exactly how steroids help combat TB is not known, but they are believed to counter the tissue-damaging effect of the inflammatory response caused by the disease.

This latest research -- which summarised the findings of existing studies from 1955 to 2012 on the effect of steroids on all types of TB -- found that there were 17 per cent less deaths overall among patients taking steroids than those who were not. The study did not demonstrate a difference in death rates between different forms of TB.

The researchers say their findings suggest that steroids could work in a systemic way that is similar for all forms of the disease. Nevertheless, they say further studies are required before steroids should be recommended for all TB patients. Such studies should investigate if the reduced death rate is seen when looking at current TB drugs only, in studies with greater numbers of patients, and if the benefits of routinely prescribing steroids for all TB would outweigh the risk of harmful side effects. Potential side effects of steroid use include increased vulnerability to other infections.

The research was carried out by a team at St George's, University of London, in partnership with Newcastle University, the University of Liverpool and the Liverpool School of Tropical Medicine. It has been published in The Lancet Infectious Diseases.

The researchers analysed results from 41 previous major TB trials on the efficacy of corticosteroids -- drugs based on hormones found in the adrenal gland, which are used to reduce inflammation. They looked at trials involving the five common forms of TB for which steroid trials had been conducted. The types of TB were pericarditis (affecting the heart), meningitis (the brain and spinal cord), peritonitis (the abdomen) and pleurisy (the membranes surrounding the lungs). In total, they examined information on 3,560 patients who took steroids and 2,982 who did not. The types of steroids, the doses and the duration of treatment varied.

As the trials took place over 57 years, the anti-TB combination drug regimens also varied. Rifampicin -- the most effective and now most widely used anti-TB drug -- was not involved in any of the 19 trials held before 1983. All but one of the trials involving pulmonary TB were held pre-rifampicin. However, the researchers did not observe any difference in death rates of patients taking steroids between current and older treatments.

Lead author Professor Julia Critchley from St George's, University of London said: "There has been debate among clinicians on whether steroids should be routinely prescribed for TB patients. At the moment they're used in a specific way to target certain organ systems, and they have been proven effective in treating the meningitis and pericarditis forms of TB, but our findings suggest that the effects in one organ system might well apply to the others in terms of an overall reduction in deaths from the disease. There could therefore be benefit in using steroids for all tuberculosis."

But Professor Critchley added: "The quality and amount of evidence we had for each type of TB varied, and most of the trials took place before the emergence of drugs resistant to anti-TB therapies, so we need to do further studies to build up a more comprehensive and up-to-date picture."

Fiona Young, a research associate in public health from Newcastle University who contributed to the study, said: "The efficacy of steroid treatment for all forms of tuberculosis suggests there is an effect on death for TB of all types, although numbers were small.

"Tuberculosis presents a major public health challenge and it's important that we determine the effects of steroids in an era where drug resistance and HIV impact upon tuberculosis treatment outcomes."

When Tuberculosis Infection Comes Back

Even if you successfully beat tuberculosis, you can get tuberculosis infection again. In fact, TB reinfection is becoming more common.

 Tuberculosis is a potentially life-threatening, airborne bacterial infection that can be found worldwide. The treatment regimen is a lengthy one, but if you stick with it and take medications the way you should, you can beat the disease. Even with treatment, however, tuberculosis reinfection is becoming a problem.

The Lengthy Tuberculosis Treatment Regimen

It's very common for people with tuberculosis to relapse during treatment. Treatment for tuberculosis symptoms can last anywhere from six months to a year, and sometimes more for drug-resistant tuberculosis. There are multiple pills that need to be taken every single day – at the same time each day, without fail – or the treatment might not work.

You may start to feel better and think that your tuberculosis has been successfully treated, only to find out that it's back – stronger and more difficult to treat. Or you may have done everything right and the disease is gone, only to find that you are infected with tuberculosis again.

How Tuberculosis Reinfection Happens

There is much debate over whether recurrent tuberculosis is caused by a relapse — getting sick again with the same strain of tuberculosis even after treatment — or tuberculosis reinfection with a new strain of the bacteria.

In the United States and Canada, it seems that most recurrent tuberculosis cases are a relapse of the original infection, perhaps because of insufficient treatment, and not because of tuberculosis reinfection with a new strain of bacteria.

The situation is different in other parts of the world. In a study done in Cape Town, South Africa, where tuberculosis is very common, 18 percent of the 612 study participants had tuberculosis reinfection. Fourteen percent of those patients had been successfully treated for their illness and were infected again with a different strain of TB.

Many people may have what's called latent tuberculosis infection, meaning that they have no tuberculosis symptoms, but the bacteria are still in their body. Once the bacteria become active and cause tuberculosis symptoms, the infection becomes active TB.

Who Gets Reinfected?

Based on the Cape Town study results, researchers did not find any risk factors that made people who had been reinfected with tuberculosis more likely to get sick again.

People who have had tuberculosis before and get it again are at a much higher risk of developing tuberculosis disease than someone who has never had the illness. More research needs to be done, but scientists suspect that some people may be more susceptible to tuberculosis than others for reasons that are not yet known.

Another study conducted on HIV-positive people infected with tuberculosis suggests that HIV makes them more susceptible to tuberculosis reinfection than non-HIV positive patients are.

Tuberculosis Reinfection Treatment

Treating recurrent tuberculosis that is caused by relapse — treatment that wasn't successful or was incomplete — is difficult. Often the bacteria have become resistant to treatment and a different combination of drugs, taken over a longer period of time, is often the recommended course of treatment.

One study showed that a main cause of drug-resistant tuberculosis, the kind that's most difficult to treat, is reinfection. Even when tuberculosis reinfection occurs from a different strain of bacteria, the recurrent type is often drug-resistant, meaning that some kind of a mutation of the original strain of bacteria doesn't respond to drugs.

If the recurrent case responds to the drugs, then it can be successfully treated. Again, the regimen must be followed to the letter.

Preventing Tuberculosis Reinfection

You can't always prevent tuberculosis, be it a primary or recurrent infection. But you can take steps to reduce your risk.

For those with HIV, one way of trying to prevent tuberculosis reinfection is to use the antibiotic isoniazid (INH). Once treatment for tuberculosis is completed, a course of preventive antibiotics might be an option to reduce the risk of tuberculosis reinfection in HIV-positive people.

The best way to prevent tuberculosis from striking again is to always take medications exactly as recommended by your doctor. And as obvious as it sounds, limiting exposure to people who may be contaminated with tuberculosis also reduces the risk of reinfection.