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Therapy
Prompt treatment of active tuberculosis is key to preventing its spread. There are several treatment options that involve combinations of drugs like isoniazid, rifampin, pyrazinamide, ethambutol and streptomycin over initial and continuation phases. Close monitoring is important due to potential adverse effects of the drugs that can impact the liver, vision or hearing. Local public health departments play an important role in treatment by arranging direct observation of therapy and follow-up care for tuberculosis patients.
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Therapy
- 1. TUBERCULOSIS TREATMENT Promptand efficient treatment of active tuberculosis is a key element in the prevention of spread of TB infection.
- 2. TB TREATMENT PLANACET (CDC, ATS) For + culture do susceptibilities and report results to Health Department Initial trtmt. = 4 drugs; at least 2 mon. INH, RIF, PZA, EMB or SM (unless likelihood of INH resistance almost non-existent) Adjust Rx when susceptibilities known DOT
- 3. TREATMENT OPTION 1Initial Phase : Daily INH, RIF, PZA & either EMB or SM X 8 wks May D/C EMB or SM if M . tb is susceptible to INH & RIF EMB or SM may not be necessary in areas with documented INH resistance <4%
- 4. TREATMENT OPTION 1(Continued) Continuation Phase : INH & RIF X 16 wks QD, 2 X wkly or 3 X wkly All regimens given 2 X wkly or 3 X wkly should be given by DOT
- 5. TREATMENT OPTION 2Initial Phase : INH, RIF, PZA & either EMB or SM QD X 2 wks, then 2 X wkly X 6 wks Continuation Phase : INH & RIF 2 X wkly for 16 wks
- 6. TREATMENT OPTION 3Treat with DOT 3 X wkly with INH, RIF, PZA, EMB or SM X 6 months Strong evidence from clinical trials to be effective Weaker evidence to D/C SM after 4 months if isolate drugs susceptible to all drugs D/C PZA before 6 months is equivocal for 3 X wk regimen No evidence of effectiveness of this regimen with EMB <6 months
- 7. ISONIAZID Adverse ReactionsHepatitis Peripheral neuropathy Lupus
- 8. INH ASSOCIATED HEPATITISNew York 1991 - 1993 Ten cases for liver biopsy Eight on INH alone Six (75%) female Median age 33 Three people < 20 years
- 9. ISONIAZID Monitoring Liverfunction tests Clinical signs of hepatic toxicity CBC Numbness/tingling of extremities
- 10. ISONIAZID Drug InteractionsAlcohol, Phenytoin, Disulfiram, Aluminum Salts, Carbamazepine, Benzodiazepines, Anticoagulants, and Ketoconazole
- 11. RIFAMPIN Adverse ReactionsHepatitis Orange discoloration of secretions Drug interactions Immunologic mediated illness
- 12. RIFAMPIN Monitoring Liverfunction tests Clinical signs of hepatic toxicity CBC, platelets, serum creatinine, bilirubin Bleeding abnormalities
- 13. RIFAMPIN Drug InteractionsWarfarin, Digoxin, Beta-blockers, Ketoconazole, Verapamil, Quinidine, Methadone, Phenytoin, Corticosteroids, Oral Contraceptives, Dapsone, Theophylline, Sulfonylureas, Cyclosporine, Protease Inhibitors
- 14. ETHAMBUTOL Adverse ReactionsGout Rash Peripheral neuritis
- 15. ETHAMBUTOL Adverse ReactionsOptic neuritis Central fibers of optic nerve decreased visual acuity central scotoma green/red vision loss Peripheral fibers of optic nerve decreased peripheral vision no loss of visual acuity rare
- 16. ETHAMBUTOL Optic NeuritisMay be time & dose dependent Rate reported at 0.8 - 6% at accepted doses At 30-40 mg/kg/d - rate may be up to 33% Visual loss may be irreversible
- 17. ETHAMBUTOL Optic Neuritis (Continued) May occur despite proper dose & visual monitoring May be delayed (months) or rapid onset (days) after start of EMB Role of zinc debated May increase risk of optic neuritis if zinc levels <0.7 mg/l
- 18. GUIDELINES BY THEJOINT TUBERCULOSIS COMMITTEE FOR PATIENTS ON EMB THERAPY Determine pretreatment renal function Recommended dose and duration should not be exceeded Record any history of eye disease Pretreatment record of Snellen visual acuity should be made. Avoid EMB in patients with significantly reduced vision who may not notice further deterioration of vision
- 19. GUIDELINES BY THEJOINT TUBERCULOSIS COMMITTEE FOR PATIENTS ON EMB THERAPY (Continued) The patient should be told that EMB may affect vision and the drug should be stopped immediately if vision is further impaired. To guard against noncompliance, explain the small risk of this happening Document that the patient has been informed about the risk of ocular toxicity with EMB
- 20. GUIDELINES BY THEJOINT TUBERCULOSIS COMMITTEE FOR PATIENTS ON EMB THERAPY (Continued) Patients complaining of ocular disturbances during therapy should be referred for a detailed ocular examination. EMB should be discontinued pending this examination Routine visual acuity testing during treatment generally is not helpful in screening for ocular toxicity Avoid EMB in patients with language or communication problems
- 21. ETHAMBUTOL Monitoring Visualacuity Uric acid levels
- 22. ETHAMBUTOL Drug InteractionAluminum salts
- 23. PYRAZINAMIDE Adverse ReactionsHepatitis Gout
- 24. PYRAZINAMIDE Monitoring Liverfunction tests Clinical signs of hepatic toxicity Uric acid levels
- 25. STREPTOMYCIN Adverse ReactionsAuditory Vestibular Nephrotoxicity Hypersensitivity
- 26. STREPTOMYCIN Monitoring Signsof Ototoxicity Vertigo Ataxia Hearing Loss
- 27. STREPTOMYCIN Drug InteractionsLoop diuretics Neuromuscular blockers
- 28. ON THE LOCALLEVEL Who treats TB here? Who interacts with Health Dept. here? Who officially reports TB to Health Dept.? How is DOT arranged here? Who has follow-up responsibility for TB patients locally?
Editor's Notes
- #2 This is the prompt slide for the TB Therapy section. This presentation will be presented at the local level by an Infectious Disease Practitioner or Pulmonary TB Control Officer. The Objectives of this presentation are to provide the attendees an understanding of the therapies used to treat TB and adverse events. The presentation is scheduled to be 30 minutes to include time for questions to be asked. Answers to some questions during the sessions may not be possible (time limitations or technical clarification needed). In such cases the speaker should request that the attendees write the question down and provide their FAX number, so that an answer to their question can be provided later. The opening statement should emphasize that prompt and efficient treatment of active tuberculosis is a key element in the prevention of spread of TB infection.