Background: Non-Steroid Anti-Inflammatory Drugs (NSAIDs) reduce pain and inflammation by
inhibiting cyclooxygenase, an enzyme in the pathway for formation of prostaglandins and
thromboxane. Prior studies have proven the role of ibuprofen (an NSAID) in modulating lung
injury and decreasing pulmonary damage in cystic fibrosis. While there has been an intense
effort by the scientific community to define the best treatment strategies for tuberculosis
immune reconstitution inflammatory syndrome (TB-IRIS), to our knowledge there is no available
study evaluating preventive strategies using anti-inflammatory agents for TB-IRIS, a highly
morbid complication in HIV-infected TB patients initiating antiretroviral therapy (ART).
Design and Methods: We propose to conduct a single center double-blind placebo-controlled
randomized trial to investigate the efficacy of daily self-administered Meloxicam (a NSAID)
versus placebo for prevention of Tuberculosis associated Immune Reconstitution Inflammatory
Syndrome (TB-IRIS). A total of 150 HIV-infected adults who are treated for Tuberculosis for
at least 2 weeks and about to initiate HIV treatment at Brewelskloof Hospital, Worcester, and
Tygerberg Teaching Hospital, Cape Town, will be randomized to one of the following
treatments: Meloxicam 7.5 mg tablet once-a-day, the experimental arm, versus Placebo tablet
once-a-day, the control arm, for 8 weeks. All patients will be followed up for 12 months.
Primary efficacy outcome: The decrease of the incidence of paradoxical TB IRIS by at least
20%; Primary safety outcome: The proportion of patients who temporarily or permanently
discontinue Meloxicam due to any adverse event (e.g. dyspepsia or gastro-intestinal upset).
Secondary outcomes are: 1) the proportion of patients in each arm with the following
indicators of TB-IRIS severity/quality of life (QOL) (degree of pain or discomfort >III,
presence of local or disseminated suppuration/abscess of any site, unscheduled clinic visits,
hospitalizations, missed more than a day at work, etc; 2) The incidence of other types of
IRIS (e.g. Kaposi Sarcoma or cryptococcal meningitis).
This study will provide important and novel data on the feasibility and efficacy of using a
cheap, widely available NSAID used in both developed and developing countries, as a
preventive intervention for TB-IRIS that could be quickly put into practice if proven to be
effective