Corticosteroids for tuberculous pleurisy

  • Review
  • Intervention

Authors


Abstract

Background

Corticosteroids used in addition to antituberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are inconsistent, raising doubt as to whether such treatment is worthwhile. Concern also exists regarding the potential adverse effects of corticosteroids, especially in HIV-positive people.

Objectives

To evaluate the effects of adding corticosteroids to drug regimens for tuberculous pleural effusion.

Search methods

In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, Current Controlled Trials, and reference lists of articles.

Selection criteria

Randomized and quasi-randomized controlled trials comparing any corticosteroid with no treatment, placebo, or other active treatment (both groups should receive the same antituberculous drug regimen) in people diagnosed with tuberculous pleurisy.

Data collection and analysis

Two authors independently assessed trial methodological quality and extracted data. Data were analysed using relative risks (RR) and mean difference (MD) with 95% confidence intervals (CI). The fixed-effect model was applied in the absence of statistically significant heterogeneity.

Main results

Six trials with 633 participants met the inclusion criteria; one trial included only HIV-positive people. Compared to control, corticosteroid use was associated with less residual pleural fluid at four weeks (RR 0.76, 95% CI 0.62 to 0.94; 394 participants, 3 trials) and reduced pleural thickening (RR 0.69, 95% CI 0.51 to 0.94; 309 participants, 4 trials). We found no evidence of an effect of corticosteroids on death from any cause (194 participants, 1 trial), respiratory function (191 participants, 2 trials), residual pleural fluid at eight weeks (399 participants, 4 trials), or pleural adhesions (123 participants, 2 trials). Although discontinuation of treatment due to adverse events was more frequent in participants receiving corticosteroids than placebo (RR 2.80, 95% CI 1.12 to 6.98; 586 participants, 6 trials), the effects were generally mild. The risk of Kaposi sarcoma may be increased in HIV-positive people receiving corticosteroids (RR 13.00, 95% CI 0.74 to 227.63; 194 participants, 1 trial).

Authors' conclusions

There are insufficient data to support evidence-based recommendations regarding the use of adjunctive corticosteroids in people with tuberculous pleurisy. Randomized controlled trials that are sufficiently powered to evaluate the effects of corticosteroids on both morbidity and mortality are needed. The effects of corticosteroids on HIV-related complications, such as Kaposi sarcoma, should be assessed in people co-infected with HIV.

摘要

背景

以皮質類固醇類藥物治療結核性胸膜炎

加入皮質類固醇於抗結核藥物來治療結核性胸膜炎已被報告有所助益。然而,不是所有的研究結果均能一致,使得人們對於這樣的治療方法發生疑慮。關於使用皮質類固醇類所可能衍生的副作用也有所顧忌,尤其是對於愛滋病毒呈現陽性反應的人們。

目標

評估在藥物療法外再增加皮質類固醇治療結核性胸腔積液的效益。

搜尋策略

2007年5月我們搜尋Cochrane Infectious Diseases Group Specialized Register, CENTRAL(Cochrane Library 2007, Issue 2) 、MEDLINE、EMBASE、LILACS、Current Controlled Trials,以及文章的參考資料清單。

選擇標準

將任何1種皮質類固醇與不採取治療、安慰劑,或是其他的積極治療(2個組別都應該要接受相同的抗結核病藥物治療方法)在結核性胸膜炎進行比較之隨機與半隨機對照試驗。

資料收集與分析

有2位作者獨立地評估了試驗方法方面的品質,並擷取出資料。這些資料都使用了相對風險(RR)以及附帶有95%信賴區間(CI)的加權平均差(WMD)來進行分析。在欠缺統計學上的顯著異質性時,就會使用固定功效的模式。

主要結論

共有包含了633名參與者的6項試驗符合了收集的標準;有1項試驗只包含了對愛滋病毒呈現陽性反應的人們。跟對照組比較起來,在4週的時候,使用皮質類固醇的患者會顯示出殘餘的胸腔積液變得較少(RR 0.76,95% CI 0.62到0.94;394名參與者,3份試驗),而且胸膜增厚的情況也減少了(RR 0.69,95% CI 0.51到0.94;309 名參與者,4份試驗)。我們並沒有發現到任何證據顯示皮質類固醇與任何成因所造成的死亡(194名參與者,共1份試驗)、呼吸功能(191名參與者,共2份試驗)、在8週時的剩餘胸腔積液(399名參與者,共4份試驗),或是胸腔沾黏(123名參與者,共2份試驗)等狀況有關。跟安慰劑比較起來,對於接受了皮質類固醇類藥物的參與者而言,雖然因為不良反應而使得治療無法連續的情況變得比較頻繁(RR 2.80,95% CI 1.12到6.98;586名參與者,共6份試驗),但是這樣的影響通常不大。愛滋病毒呈現陽性反應且又接受皮質類固醇類藥物的人們Kaposi肉瘤的風險可能會增加(RR 13.00,95% CI 0.74到227.63;194名參與者,共1項試驗)。

作者結論

並沒有足夠的資料能夠推薦在患有結核性胸膜炎的人們身上使用皮質類固醇類藥物作為輔助治療。以效力足夠的隨機對照試驗來評估皮質類固醇類藥物對併發症與致命的影響有其必要。在受到愛滋病毒共同感染的人們身上,應該還要對皮質類固醇類藥物對與愛滋病毒有關的併發症,如Kaposi肉瘤,進行評估。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於結核病而言,並沒有明確的證據顯示皮質類固醇類藥物是有功效的。結核性胸腔積液是由結核病感染肋膜形成。這樣的現象會造成肺部周圍的體液產生聚集使呼吸功能受到阻礙,長期以後還有可能會導致肺部功能受限。有些臨床醫師相信,將皮質類固醇類藥物搭配抗結核病藥物共同使用可以幫助人們預防這些併發症產生。我們發現,對於結核性胸腔積液的人們而言,不管愛滋病毒的狀態如何,都沒有明確的證據可以支持使用皮質類固醇類藥物。然而,對於受到愛滋病毒感染的人們而言,僅有1項試驗曾經評估過使用皮質類固醇類藥物的優點與危害。

Plain language summary

No clear evidence that corticosteroids are effective for tuberculous

Tuberculous pleural effusion results from tuberculous infection of the membrane covering of the lungs. This results in a build up of fluid around the lung that impairs breathing and may lead to restriction of lung function in the long term. Some clinicians believe that corticosteroids used in combination with antituberculous drugs can help to prevent these complications. We found no clear evidence supporting the use of corticosteroids in people with tuberculous pleural effusion, regardless of HIV status. However, only one trial evaluated the balance between benefit and harm of corticosteroids in people infected with HIV.

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