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Bucher et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection. Cochrane Database Syst Rev. 2006;(3):CD006150.
Bozzette et al. A controlled trial of early adjunctive treatment with corticosteroids for pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. NEJM. 1990; 323(21):1451-57.
Gallant e tal. The effect of adjunctive corticosteroids for the treatment of pneumocystis carinii pneumonia on mortality and subsequent complications. Chest. 1998;114(5):1259-63.

Efficacy Endpoints

Mortality

Harm Endpoints

Increase in AIDS-related Complications

Narrative

Pneumocystits jiroveci pneumonia (PCP), formerly know as Pneumocystis carinii pneumonia, is the most common opportunistic infection among people with human immunodeficiency virus (HIV), and mortality remains high at 10 to 20% during the initial infection.

This review examined the role of corticosteroids among HIV patients with PCP and hypoxemia defined as arterial oxygen partial pressure <70mmHg or an alveolar-arterial gradient >35 mmHg on room air. The authors included six trials with 489 patients that randomized subjects to receive either corticosteroids or placebo as an addition to antimicrobials. The review reported outcomes for undeveloped nations with minimal access to antiretroviral therapy and for developed nations with access. Control group mortality rates were 25% and 10% in these two groups, respectively.

Note that despite the greater number of patients that will experience a harmful effect of steroids, the beneficial effect is of greater impact to most patients. Based on this value judgment we classified the therapy as beneficial overall (a green light).

Most of the studies gave intravenous methylprednisolone with a starting dose of either 40mg or 60mg every 6 hours, then tapered over 18 to 24 days. Two studies gave a burst of methylprednisolone for 10 days with no taper at either 40mg every 12 hours or based on weight (2mg/kg every 6 hours). Two studies gave oral prednisone at either 80mg per day for five days or 60mg per day for 7 days and then tapered to complete a course of 21 days.

Caveats

The pooled study population was small with only 489 subjects, and only three of the six studies were completed and fully published. One study was published only in abstract form and the other two were stopped early because of benefit. Overall, there was moderate heterogeneity in the pooled results for mortality at 1 month (P=0.12; I2=43%), but the results became homogeneous at 3-4 months (P=0.46; I2=0%). In terms of harm, the data is scant. Only two studies reported harms.

Author

Jarone Lee, MD, MPH

Published/Updated

August 19, 2010