期刊
NEW ENGLAND JOURNAL OF MEDICINE
卷 379, 期 20, 页码 1915-1925出版社
MASSACHUSETTS MEDICAL SOC
DOI: 10.1056/NEJMoa1800762
关键词
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资金
- European and Developing Countries Clinical Trials Partnership [SP.2011.41304.074]
- Institute of Tropical Medicine
- Wellcome Trust [098316, 084323, 104803, 203135]
- Institute for Tropical Medicine
- South African Research Chairs Initiative of the Department of Science and Technology [64787]
- National Research Foundation (NRF) of South Africa, NRF [85858]
- South African Medical Research Council through its TB and HIV Collaborating Centres Programme - National Department of Health [SAMRC-RFA-CC: TB/HIV/AIDS-01-2014]
- Francis Crick Institute - Wellcome [10218]
- Cancer Research UK
- Imperial College London, from the Department of Science and Technology of the government of South Africa
- Research Councils UK
- MRC [MC_U117588499] Funding Source: UKRI
BACKGROUND Early initiation of antiretroviral therapy (ART) in human immunodeficiency virus (HIV)-infected patients who have tuberculosis reduces mortality among patients with low CD4 counts, but it increases the risk of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (IRIS). METHODS We conducted this randomized, double-blind, placebo-controlled trial to assess whether prophylactic prednisone can safely reduce the incidence of paradoxical tuberculosis-associated IRIS in patients at high risk for the syndrome. We enrolled HIV-infected patients who were initiating ART (and had not previously received ART), had started tuberculosis treatment within 30 days before initiating ART, and had a CD4 count of 100 cells or fewer per microliter. Patients received either prednisone (at a dose of 40 mg per day for 14 days, then 20 mg per day for 14 days) or placebo. The primary end point was the development of tuberculosis-associated IRIS within 12 weeks after initiating ART, as adjudicated by an independent committee. RESULTS Among the 240 patients who were enrolled, the median age was 36 (interquartile range, 30 to 42), 60% were men, and 73% had microbiologically confirmed tuberculosis; the median CD4 count was 49 cells per microliter (interquartile range, 24 to 86), and the median HIV type 1 RNA viral load was 5.5 log(10) , copies per milliliter (interquartile range, 5.2 to 5.9). A total of 120 patients were assigned to each group, and 18 patients were lost to follow-up or withdrew. Tuberculosis-associated IRIS was diagnosed in 39 patients (32.5%) in the prednisone group and in 56 (46.7%) in the placebo group (relative risk, 0.70; 95% confidence interval [CI), 0.51 to 0.96; P=0.03). Openlabel glucocorticoids were prescribed to treat tuberculosis-associated IRIS in 16 patients (13.3%) in the prednisone group and in 34 (28.3%) in the placebo group (relative risk, 0.47; 95% CI, 0.27 to 0.81). There were five deaths in the prednisone group and four in the placebo group (P=1.00). Severe infections (acquired immunodeficiency syndrome-defining illnesses or invasive bacterial infections) occurred in 11 patients in the prednisone group and in 18 patients in the placebo group (P=0.23). One case of Kaposi's sarcoma occurred in the placebo group. CONCLUSIONS Prednisone treatment during the first 4 weeks after the initiation of ART for HIV infection resulted in a lower incidence of tuberculosis-associated IRIS than placebo, without evidence of an increased risk of severe infections or cancers.
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