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TB Treatment Regimen. Gina S. de los Reyes, M.D., FPCP, FPCCP. Outline. Short Course Treatment; Fixed Dose Combination Classification of TB Cases Treatment Regimens Treatment of TB in Special Situations Symptom-based approach to adverse effects of TB drugs. Who requires treatment for PTB?. - PowerPoint PPT Presentation
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TB Treatment Regimen
Gina S. de los Reyes, M.D., FPCP, FPCCP
Outline
Short Course Treatment; Fixed Dose Combination
Classification of TB Cases Treatment Regimens Treatment of TB in Special Situations Symptom-based approach to adverse effects
of TB drugs
Who requires treatment for PTB? 1. Active PTB (Class 3)
2. Inactive PTB (Class 4) but with no previous adequate/completed treatment
3. TB suspect (Class 5) when the probability of TB is high, while awaiting confirmation
Aims of Treatment 1. To cure patients with the least interference with their lives. 2. To prevent death in seriously ill patients. 3. To prevent extensive damage to the lungs with the consequent complications.
4. To avoid relapse of the disease.
5. To prevent the dev’t of drug-resistant T.B (acquired resistance).
6. To protect his/her family and the
community from infection.
Anti-TB drugs : Actions & Adverse EffectsFirst line drugs
Gastro’nal
Cutaneous rxn
Hepatitis
BactericidalRifampicin
Hepatitis
Peripheral Neuropathy
BactericidalIsoniazid
Adverse Effects
ActionDrug
Anti-TB drugs
Ototoxicity
Cutaneous
Hypersen-
sitivity
BactericidalStreptomycin
Hepatotoxicity
Arthralgia
BactericidalPyrazinamide
Retrobulbar neuritis
BacteriostaticEthambutol
Second-line drugs
Ethionamide Prothionamide Sodium para-
aminosalicylate (PAS) Cycloserine Ofloxacin Ciprofloxacin
Capreomycin Kanamycin Viomycin Amikacin Co-amoxiclav Clarithromycin Rifamycin derivatives-
Rifabutin, Rifapentene
Drug Doses
Dosage in mg/kg (range)
Drug Daily Thrice/week
Isoniazid 5 10
(4-6) (8-12)
Rifampicin 8 10
(8-12) (8-12)
Drug Doses
Pyrazinamide 25 35
(28-30) (30-40)
Ethambutol 15 30
(15-20) (25-35)
Streptomycin 15 15
(12-18) (12-18)
FIXED- DOSE COMBINATION (FDC) ANTI-TB DRUGS
Formulation where two or more anti-TB drugs are present in fixed proportions
Advocated by WHO & the International Union Against Tuberculosis & Lung Diseases (IUATLD) to replace single-drug preparations as treatment for TB
FDCs
For the patient: simplified drug intake
Fewer pills to swallow Pills are identical Correct regimen is followed
FIXED DOSE COMBINATION: SIMPLER DOSE COMPUTATION
Body Weight (kg) 4-FDC (HRZE)
37 to 54 3 tablets
55 to 70 4 tablets
> 70 5 tablets
Practical dosing:
< 55 kg: 3 tablets daily > 55 kg: 4 tablets daily
Short Course Chemotherapy6 months regimen which includes
Rifampicin and Pyrazinamide
Standard Treatment- at least 12 months (w/o Rifampicin)
2 Phases of SCC
Intensive phase- 2 months
Continuation phase- 4 months
Short Course Chemotherapy Advantages
Easy to take Pt feels better quickly Sputum becomes (-) quickly Relapse rate lower If relapse occurs, TB remains sensitive Much cheaper than standard tx
Objectives of SCC
To achieve better bactericidal and sterilizing activities
To prevent emergence of resistance
Resistant Mutants
Small number which are naturally resistant More will occur in TB cavity If only one drug is given the sensitive TB are
destroyed but the resistant ones multiplyNEVER GIVE A SINGLE DRUG
(MONOTHERAPY)
Classification of TB Cases
Pulmonary TBSmear (+)Smear (-)
Extrapulmonary TB
PTB-Smear Positive
At least 2 sputum specimens (+) for AFB +/- X-ray abnormalities consistent with
active TB 1 sputum specimen (+) for AFB
and with X-ray abnormalities consistent with active TB
1 sputum specimen (+) for AFB with sputum culture (+) for M.
tuberculosis
PTB – Smear Negative
At least 3 sputum specimens (-) for AFB
X-ray abnormalities consistent with active TB
No response to a course of antibiotics and/or symptomatic medications
Decision by a medical officer to treat with anti-TB drugs
Extrapulmonary TB At least 1 mycobacterial smear/culture (+)
from an extrapulmonary site (organs other than the lungs: pleura, lymph nodes,
gut, skin, joints, bones, meninges, intestines, peritoneum, pericardium, etc)
Histological and/ or clinical evidence consistent with active TB & there is decision by a Medical Officer to treat pt with anti-TB drugs
Types of TB Cases New Relapse Failure Return after default (RAD) Transfer-in Other
Types of TB Cases New- pt who has never had tx for TB or who
has taken anti-TB drugs for < 1month
Relapse - pt. previously treated for TB, has been declared cured or tx completed, and is diagnosed with ( + ) smear or culture for TB
Failure- pt while on tx is sputum smear ( + ) at 5 months or later during the course of tx
Types of TB Cases Return after default
A patient who returns to treatment with positive bacteriology (smear or culture), following interruption of treatment for 2 months or more.
Transfer-in- pt who has been transferred from another facility with proper referral slip to continue
Types of TB Cases Other 1. Pt starting treatment again after interrupting
treatment for >2 mos. and has remained smear (-)
2. Pt who was initially registered as new smear-negative case, turned out to be smear (+) during the tx.
3. Chronic case: pt who is sputum(+) at the end of a re-treatment regimen.
Each standard drug is indicated by a capital letter.H- Isoniazid
R- Rifampicin Z- Pyrazinamide
E- Ethambutol S- Streptomycin
Treatment Regimens
Treatment RegimensRegimen TB Patient
Regimen I2HRZE/4HRE
New pulmonary smear (+ ) casesNew seriously ill pulmonary smear (-) cases with extensive parenchymal involvementNew severely ill extra-pulmonary TB cases
Treatment RegimensRegimen TB Patient
Regimen II:2HRZES/1HRZE/5HRE
Failure casesRelapse casesRAD (smear +)Other (smear +)
Treatment RegimensRegimen TB Patient
Regimen III:2HRZ/4HR
New smear (-) but with minimal PTB on x-ray as confirmed by Medical Officer New extra-pulmonary TB (not serious)
Treatment of TB in Special Situations
TB in pregnancy/lactation TB in pts with hepatic disease TB in pts with renal disease TB in the elderly TB in HIV/AIDS
Tuberculosis in Pregnancy
INH, Ethambutol & Rifampicin can be used
Not recommended: Pyrazinamide, Streptomycin, Kanamycin, Capreomycin
Consensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)
TB treatment in Pregnancy
Non-cavitary Disease -9HRE Cavitary Disease- 12HRE
Consensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)
TB and Lactation
Breast feeding not discouraged Anti-TB drug concentration - low,
non-toxic & non-therapeutic in breast milk
Consensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)
TB treatment & Liver Disease
Hepatitis virus carriage or a past hx of acute hepatitis w/o clinical evidence of chronic liver disease
Rx- Usual short course chemotherapyestablished chronic liver disease
2SHRE/6HR2SHE/10 HE
TB treatment & Liver Disease
Hepatic failure Streptomycin & Ethambutol can be given.If a third drug is needed, Isoniazid or
Rifampicin can be given cautiously in lowered doses
Acute Hepatitis – defer until hepatitis resolved or 3SE/6HR
TB treatment & renal insufficiency/
renal failure
Isoniazid, Rifampicin & Pyrazinamide can be given in normal dosages
2HRZ/6HR
Others TB in the Elderly
9HR
TB in HIV + with susceptibility testing
2HRZE/4-7HR
w/o susceptibility testingNon-cavitary- 9HRZECavitary -12HRZE
Symptom-based approach to adverse effects of TB drugs
Reassure the patient
Rifampicin3. Orange/red
Colored urine
Give anti-histamine
Any kind of drugs
2. Mild skin reactions
Give medication at bedtime
Rifampicin1. Gastro-intestinal intolerance
ManagementDrugs responsible
Side-effects
(Minor)
Pyridoxine (Vit B6) 100-200 mg for tx;
10mg for prevention
Isoniazid5. Burning sensation of the feet
Warm compress;
Rotate sites of injection
Streptomycin4. Pain at injection site
ManagementDrug(s) responsible
Side effects
AntipyreticsRifampicin7. Flu-like symptoms(fever, inflammation of the resp. tract)
Aspirin or NSAIDAllopurinol
Pyrazinamide6. Arthralgia
ManagementDrug(s) responsible
Side effects
Discontinue Anti-TB drugs
Any kind of drugs (esp Strep)
1. Severe skin rash due to hypersensitivity
D/C anti-TB drugs
If sx subside, resume tx and monitor
Any kind of drugs (esp Isoniazid, Rifampicin and Pyrazinamide
2. Jaundice due to hepatitis
ManagementDrug(s) responsible
Major side effects
Discontinue Ethambutol & refer to an opthalmologist
Ethambutol3. Impairment of visual acuity & color vision (optic neuritis)
Discontinue Streptomycin
Streptomycin4. Hearing impairment, tinnitus, vertigo
ManagementDrug(s) responsible
Major side effects
Major side effects
Drug(s) responsible
Management
5. Oliguria or albuminuria due to renal disorder
StreptomycinRifampicin
DiscontinueStrep, Rifampicin
6. Psychosis & convulsion
Isoniazid Discontinue Isoniazid
7.Thrombo-cytopenia, anemia, shock
Rifampicin Discontinue Rifampicin
Thank You for your kind attention!
2HRZE/4HR
2H3R3Z3E3/4H3R3
Challenge doses for detecting cutaneous or hypersensitivity to anti-TB drugs
Day 1 Day 2
Challenge Doses
Isoniazid 50mg 300mg
Rifampicin 75mg 300mg
Pyrazinamide 250mg 1.0g
Ethambutol 100mg 500mg
Streptomycin 125mg 500mg
Drug