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Re: Evidence-based treatment of tuberculous pericarditis

Dear Editor

I would like to point out that Maisch and Ristic's recomendations [1] on the duration of treatment and the use of adjuvant steroids in tuberculous pericarditis are not consistent with the best available evidence. They advise treatment for '9-12 months' with anti-tuberculous drugs. In a recent systematic review of clinical trials of antituberculous chemotherapy in patients with tuberculous pericarditis, we found no evidence that treatment for 9 months or more was any better than treatment for the standard duration of 6 months.[2] Thus, the current recommendation is that these patients should be treated with stanrd antituberculous chemotherapy for 6 months.[3]

Furthermore, a meta-analysis of trials of the the effectiveness of adjuvant steroids in tuberculous pericarditis showed promising but inconclusive results.[4] These trials included very small numbers of patients with HIV infection, and the potentially harmful side effects of steroid use in immunocompromised patients has not been examined adequately.[5] Therefore, the routine use of adjuvant steroids in all patients with tuberculous pericarditis (as recommended by Maisch and Rustic) is not supported by current best evidence. The effectiveness and safety of adjuvant corticosteroids in tuberculous pericarditis remains to be established in large, well-designed placebo-controlled trials that involve adequate numbers of HIV postive patients.[2,3,4].

References

(1) Maisch B, Ristic AD. Practical aspects of the management of pericardial disease. Heart 2003;89:1096-1103.

(2) Mayosi BM, Ntsekhe M, Volmink JA, Commerford PJ. Tuberculous pericarditis treatment (Cochrane Review). In The Cochrane Library, Issue 4, 2001. Oxford: Update Software.

(3) Mayosi BM, Volmink JA, Commerford PJ. Pericardial disease: an evidence based approach to diagnosis and treatment. In Evidence Based Cardiology, 2nd edition, Yusuf S, Cairns JA, Camm AJ, Fallen EL, Gersh BJ, (Eds). London: BMJ Books, 2002:735-48.

(4) Ntsekhe M, Wiysonge C, Volmink J, Commerford PJ, Mayosi BM. Adjuvant corticosteroids for tuberculous pericarditis: promising, but not proven. QJM 2003;96:593-599.

(5) Elliott AM, Halwaiindi B, Bagshawe A, et al. Use of prednisolone in the treatment of HIV-positive tuberculosis patients. QJM 1992;85:855-60.