Drug contraindicated for HIV pleural tuberculosis

Prednisolone, a glucocorticoid that is sometimes added to antituberculosis drug regimens, should not be used to treat patients with pleural tuberculosis and HIV infection, nor can it be recommended for those with pleural tuberculosis who are not coinfected with HIV, according to a study in the Aug. 15 issue of The Journal of Infectious Diseases.

Researchers conducted a double-blind, placebo-controlled study of prednisolone in 197 patients with HIV-1-associated pleural tuberculosis. The expectation was that the drug might retard HIV progression and thus prolong survival. In fact, it had no effect on survival but did increase the risk of the AIDS-related cancer Kaposi’s sarcoma.

The authors performed their study at the National Tuberculosis Treatment Centre in Kampala, Uganda, between November 1998 and January 2002. Of the 197 patients studied, 99 were given prednisolone, and 98, a placebo, along with standard tuberculosis treatment.

The patients receiving prednisolone did see improvement in the principal signs and symptoms of pleural tuberculosis, especially anorexia, weight loss, and cough. Although prednisolone use was not associated with such HIV-associated opportunistic diseases as cryptococcal meningitis, esophageal or oral candidiasis, herpes zoster, or oral or genital herpes simplex infection, it did significantly increase the risk of Kaposi’s sarcoma. Six cases were observed in the prednisolone group only. A previous Zambian study also had found that Kaposi’s sarcoma occurred only in a group given prednisolone to treat pleural tuberculosis.

Given an increased risk of Kaposi’s sarcoma, no improvement in survival, and no reported long-term benefits of glucocorticoids in patients with pleural tuberculosis who were not HIV-infected, the authors concluded that pleural tuberculosis should not be treated with prednisolone, regardless of HIV status. This recommendation did not extend to other uses of prednisolone, such as treatment of pericardial tuberculosis or Pneumocystis carinii pneumonia.

They warned, however, that "prednisolone should be used with caution in situations where no beneficial effect on immediate survival can be expected."