Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults.

Abstract

BACKGROUND:

Tuberculous meningitis kills or disables more than half of those affected with the disease. Previous studies have been too small to determine whether adjunctive treatment with corticosteroids can reduce the risk of disability or death among adults with tuberculous meningitis, and the effect of coinfection with the human immunodeficiency virus (HIV) is unclear.

METHODS:

We performed a randomized, double-blind, placebo-controlled trial in Vietnam in patients over 14 years of age who had tuberculous meningitis, with or without HIV infection, to determine whether adjunctive treatment with dexamethasone reduced the risk of death or severe disability after nine months of follow-up. We conducted prespecified subgroup analyses and intention-to-treat analyses.

RESULTS:

A total of 545 patients were randomly assigned to groups that received either dexamethasone (274 patients) or placebo (271 patients). Only 10 patients (1.8 percent) had been lost to follow-up at nine months of treatment. Treatment with dexamethasone was associated with a reduced risk of death (relative risk, 0.69; 95 percent confidence interval, 0.52 to 0.92; P=0.01). It was not associated with a significant reduction in the proportion of severely disabled patients (34 of 187 patients [18.2 percent] among survivors in the dexamethasone group vs. 22 of 159 patients [13.8 percent] in the placebo group, P=0.27) or in the proportion of patients who had either died or were severely disabled after nine months (odds ratio, 0.81; 95 percent confidence interval, 0.58 to 1.13; P=0.22). The treatment effect was consistent across subgroups that were defined by disease-severity grade (stratified relative risk of death, 0.68; 95 percent confidence interval, 0.52 to 0.91; P=0.007) and by HIV status (stratified relative risk of death, 0.78; 95 percent confidence interval, 0.59 to 1.04; P=0.08). Significantly fewer serious adverse events occurred in the dexamethasone group than in the placebo group (26 of 274 patients vs. 45 of 271 patients, P=0.02).

CONCLUSIONS:

Adjunctive treatment with dexamethasone improves survival in patients over 14 years of age with tuberculous meningitis but probably does not prevent severe disability.

• Authors: Guy E Thwaites, Duc Bang Nguyen, Huy Dung Nguyen, Thi Quy Hoang, Thi Tuong Oanh Do, Thi Cam Thoa Nguyen, Quang Hien Nguyen, Tri Thuc Nguyen, Ngoc Hai Nguyen, Thi Ngoc Lan Nguyen, Ngoc Lan Nguyen, Hong Duc Nguyen, Ngoc Tuan Vu, Huu Hiep Cao, Thi Hong Chau Tran, Phuong Mai Pham, Thi Dung Nguyen, Kasia Stepniewska, Nicholas J White, Tinh Hien Tran, Jeremy J Farrar
• Journal: The New England journal of medicine (N Engl J Med) Vol. 351 Issue 17 Pg. 1741-51 (Oct 21 2004) ISSN: 1533-4406 [Electronic] United States
• PMID: 15496623 (Publication Type: Clinical Trial, Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
• Copyright: Copyright 2004 Massachusetts Medical Society.

Chemical References

• Adjuvants, Immunologic
• Glucocorticoids
• Dexamethasone

Topics

• AIDS-Related Opportunistic Infections (drug therapy)
• Adjuvants, Immunologic (therapeutic use)
• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Dexamethasone (adverse effects, therapeutic use)
• Double-Blind Method
• Female
• Glucocorticoids (adverse effects, therapeutic use)
• HIV Infections (complications)
• Humans
• Male
• Middle Aged
• Multivariate Analysis
• Survival Analysis
• Tuberculosis, Meningeal (complications, drug therapy, mortality)