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Module 4
Basic Principles of Treatment
“ubo! ubo! ubo!”(cough for 2 weeks or more)
Did not Did not taketake
medicatiomedicatio
nn
In Loving Memory ofIn Loving Memory of
DEADDEAD
Not taking medicationNot taking medication
Cough worsens
Did not Did not taketake
medicationmedication
Active TB Patient
“ubo! ubo! ubo!”(cough for 2 weeks or more)
Not regularly taking Not regularly taking medicationmedication
Takes medication
Medication is Discontinued or
irregular
Coughing recurs & Bacteria multiplies
Feels better but bacteria is still present in the lungs
Active TB Patient
Takes medication (2 mos.)
Takes medication (4-6 mos.)
Feels better but bacteria is still present in the lungs cured
Regularly taking medicationRegularly taking medication
“ubo! ubo! ubo!”(cough for 2 weeks or more)
Active TB Patient
Patients should be given the safest, most effective therapy in prescribed duration.
Multiple drugs to which the organisms are (likely) susceptible must be chosen.
Addition of a single drug to a failing regimen is not recommended.
Patient’s complete adherence to therapy must be ensured. – DOTS for all!
Basic Principles of Treatment
FIRST LINE ESSENTIAL DRUGSRifampicin – bactericidal, extra/intra-
cellular
Isoniazid – bactericidal, extra-cellular
FIRST LINE SUPPLEMENTAL DRUGSPyrazinamide – weakly bactericidal, w/in
macrophages, acute inflammation
Ethambutol – bacteriostatic/cidal at higher doses; extra/intra cellular
Streptomycin – bactericidal
Basic Principles of Treatment
• Interacts with oral contraceptive pills, seizure meds, warfarin, methadone / opiates
• Major side effects: Hepatitis (nausea, vomiting, abdominal pain, jaundice)– Contraindicated in GI distress and rash
– Bleeding problems, flu-like symptoms
– Risk increases with alcoholism, liver disease, and use of other hepatotoxic drugs
Rifampicin
• Major side effects: Hepatitis (nausea, vomiting, abdominal pain, jaundice)
• Risk increases with alcoholism, presence of liver disease, use of other medications– Other contraindications: GI distress and rash
– Occasional peripheral neuropathy preventable with Vitamin B6 supplementation
Isoniazid
• Major side effects: Hepatitis (nausea, vomiting, abdominal pain, jaundice)
• Risk increases with liver disease, alcoholism, other hepatotoxic drugs– Other common C/I include GI distress and rash
– Joint aches, and hyperuricemia
Pyrazinamide
• Major side effects: Optic Neuritis (blurred vision, altered color vision)
• Visual monitoring suggested while on treatment
Ethambutol
• Administered via intra-mascular (IM) route
• May be substituted by kanamycin, capreomycin, or amikacin.
• Major side effects: ear damage (balance problems, hearing loss, ringing in the ear); kidney damage
Streptomycin
ReassuranceRifampicinOrange-red urine
Pyridoxine 100mg/day
IsoniazidBurning sensation
Aspirin/ NSAIDSPyrazinamideJoint pains
Give drugs last thing at night
RifampicinAnorexia, nausea, abdominal pain
Minor
ManagementDrugs probably responsible
Side effects
Symptom-based Approach to Adverse Effects of TB Drugs
Stop RifampicinRifampicinShock, Purpura, ARF
Stop EEthambutolVisual impairment (other causes excluded)
Stop drugs, urgent liver function tests and PT
Most anti-TB drugs
Vomiting and Confusion (suspect drug-induced liver failure)
Stop drugs, re-introduce
Isoniazid, Rifampicin, PZA
Jaundice
Stop S, use EStreptomycinDizziness (vertigo and nystagmus)
Stop S, use EStreptomycinDeafness (no gross abnormality on otoscopy)
Major
Symptom-based Approach to Adverse Effects of TB Drugs