Tuberculous pericarditis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Ahmed Zaghw, M.D. [2]

Anti-Tuberculosis Chemotherapy

With the use of antituberculosis chemotherapy, survival rate in tuberculous pericarditis has improved dramatically. Mortality rate in preantibiotic era was 80-90%. At present it is 8-17% and 17-34% if associated with HIV. A 2months course of isoniazid, pyrazinamide, rifampicin, and ethambutol followed by 4months course of isoniazid and rifampicin is shown to be effective. Short course chemotherapy is beneficial in HIV infected patients. Antituberculous therapy has an additional clinical benefit in reduction of constrictive pericarditis, from 88 % down to 10-20 % of treated cases.

The treatment regimen varies among 3 patient groups; sero-negative HIV, sero-positive HIV and drug-resistant tuberculosis.

Empirical Anti-Tuberculosis Therapy

It should be considered that in developing countries where TB is endemic and in cases with high clinical suspicion of tuberculous pericarditis, starting with empiric antituberculous therapy is appropriate before establishing a definitive diagnosis. In the clinical settings where the diagnosis cannot be established based on bacteriology, histology, or pericardial fluid analysis, clinical response to antituberculous therapy serves as support for a diagnosis of tuberculous pericarditis. In developed countries where TB is not endemic, antituberculous therapy should generally not be initiated empirically in the absence of definitive diagnosis.

Statandard regimens for new TB patients (with presumed, or known, to have drug-susceptible TB)

Statandard regimens for new TB patients with drug-susceptible TB Intensive Initial Phase ▸ Initial Phase: 2 months of HRZE † Continuation phase ▸ Continuation Phase: 4 months of HR

† WHO no longer recommends omission of ethambutol during the intensive phase of treatment for patients with non-cavitary, smear-negative PTB or EPEPTB who are known to be HIV-negative.

Statandard regimens for new TB patients( with known or suspected high levels of isoniazid resistance TB)

Statandard regimens for new TB patients with isoniazid resistance TB Intensive Initial Phase ▸ Initial Phase: 2 months of HRZE † Continuation phase ▸ Continuation Phase: 4 months of HRE

2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR in these patients or if such data are not available

Dosing Frequency for New TB Adult Patients with Active Tuberculosis caused by Drug-Susceptible Organisms

Dosing Frequency for New TB Adult Patients with Active Tuberculosis caused by Drug-Susceptible Organisms Optimal first line ▸ Initial Phase: Daily ▸ Continuation Phase: Daily Alternative line in DOT ▸ Initial Phase: Daily ▸ Continuation Phase: Three times a week Alternative line accepted in limited situations † ▸ Initial Phase: Three times a week ▸ Continuation Phase: Three times a week

DOT; Direct Observed Therapy

† if patient is getting DOT and not living with HIV infected patient or HIV prevalent setting

The level of evidence of the dosage frequency came from the systematic review showed that equivalent efficacy of daily intensive-phase dosing followed by two times weekly continuation phase, however twice weekly dosing is not recommended on operational grounds. Also showed that the daily (rather than three times weekly) intensive-phase dosing may also help to prevent acquired drug resistance in TB patients starting treatment with isoniazid resistance. The systematic review found that patients with isoniazid resistance treated with a three times weekly intensive phase had significantly higher risks of failure and acquired drug resistance than those treated with daily dosing during the intensive phase.

Role of Corticosteroids in Tuberculous pericarditis

The corticosteroids can shorten the time to resolution of clinical symptoms, decrease reaccumulation of fluid and reduce the mortality. But none of the study results were statistically significant. However, other studies claimed that corticosteroids do not appear to affect the likelihood of pericardial effusion reaccumulation or progression to constrictive pericarditis.

The American Thoracic Society, CDC, and Infectious Diseases Society of America recommends in 2003 the use of corticosteroids (prednisone) as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of antituberculosis therapy. However the Infectious Diseases Society of America recommends a shorter course of 60 mg of prednisone daily, get tapered by 10/mg day each week over a six-week period in HIV. In contrary to the standard full 11 week course, the 6 week course has demonstrated efficacy in HIV-seropositive patients with tuberculous pericarditis.

Prednisone Doses in Tuberculous Pericarditis Adult dose (11 wks) ▸ prednisone †: 60 mg/day given for 4 weeks, followed by: 30 mg/day for 4 weeks, then: 15 mg/day for 2 weeks, finally: 5 mg/day for week 11 (the final week) Pediatrics dose ▸ prednisone: weight adjusted dosage beginning with 1 mg/kg body weight, taper the dose as described for adults

† or the equivalent dose of prednisolone