Presentation on theme: "Gina S. de los Reyes, M.D., FPCP, FPCCP"— Presentation transcript:
1 Gina S. de los Reyes, M.D., FPCP, FPCCP TB Treatment RegimenGina S. de los Reyes, M.D., FPCP, FPCCP
2 Outline Short Course Treatment; Fixed Dose Combination Classification of TB CasesTreatment RegimensTreatment of TB in Special SituationsSymptom-based approach to adverse effects of TB drugs
3 Who requires treatment for PTB? 1. Active PTB (Class 3)2. Inactive PTB (Class 4) but with no previousadequate/completed treatment3. TB suspect (Class 5) when the probability ofTB is high, while awaiting confirmation
4 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 lungswith 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 thecommunity from infection.
5 Anti-TB drugs : Actions & Adverse Effects First line drugs Gastro’nalCutaneous rxnHepatitisBactericidalRifampicinPeripheral NeuropathyIsoniazidAdverse EffectsActionDrug
10 FIXED- DOSE COMBINATION (FDC) ANTI-TB DRUGS Formulation where two or more anti-TB drugs are present in fixed proportionsAdvocated by WHO & the International Union Against Tuberculosis & Lung Diseases (IUATLD) to replace single-drug preparations as treatment for TBFDC anti-TB combinations (1)The other key strategy is the use of fixed dose combinations or FDCs.FDC are formulations where 2 or more anti-TB drugs are present in fixed proportion in a single tablet.FDCs have been recommended by the WHO and the IUATLD as the preferred mode of TB treatment, to replace single drug preparations.
11 FDCs For the patient: simplified drug intake Fewer pills to swallow Pills are identicalCorrect regimen is followedFDCs (2)For the patient, the ritual of taking the pills is very much simplifiedFor one, the patient, in most cases, will be taking a fewer numbers of pills,Second, all the pills are identical and therefore, there is no confusion what to take firstThird, he is assured that he is taking the correct regimen.All in all, these factors should result in better adherence to the treatment.
12 FIXED DOSE COMBINATION: SIMPLER DOSE COMPUTATION Body Weight (kg)4-FDC (HRZE)37 to 543 tablets55 to 704 tablets> 705 tabletsFDC: simple dose computationUsing FDC, the number of tablets to take is never more than 5, and only depends on the actual body weight.To make it even simpler, for most Filipinos, the magic number is 55 kgs. 55 kg or more requires 4 tablets while those less than 55 kgs take only 3 tablets.Practical dosing:< 55 kg: 3 tablets daily > 55 kg: 4 tablets daily
13 Short Course Chemotherapy 6 months regimen which includes Rifampicin and PyrazinamideStandard Treatment- at least 12 months (w/o Rifampicin)
14 2 Phases of SCCIntensive phase monthsContinuation phase- 4 months
15 Short Course Chemotherapy Advantages Easy to takePt feels better quicklySputum becomes (-) quicklyRelapse rate lowerIf relapse occurs, TB remains sensitiveMuch cheaper than standard tx
16 Objectives of SCCTo achieve better bactericidal and sterilizing activitiesTo prevent emergence of resistance
17 Resistant Mutants Small number which are naturally resistant More will occur in TB cavityIf only one drug is given the sensitive TB are destroyed but the resistant ones multiplyNEVER GIVE A SINGLE DRUG (MONOTHERAPY)In any population of TB there will be a small number which are naturally resistant. More of them will occur among the millions of TB in any TB cavity. If only one drug is given the sensitive TB are destroyed but the resistant ones multiply. NEVER GIVE A SINGLE DRUG (MONOTHERAPY).
18 Classification of TB Cases Pulmonary TBSmear (+)Smear (-)Extrapulmonary TB
19 PTB-Smear Positive +/- X-ray abnormalities consistent with active TB At least 2 sputum specimens (+) for AFB+/- X-ray abnormalities consistent with active TB1 sputum specimen (+) for AFBand with X-ray abnormalities consistent with active TBwith sputum culture (+) for M. tuberculosisNormal cxr but with dse-15-20%18% firbocalcific has smear positive
20 PTB – Smear Negative At least 3 sputum specimens (-) for AFB X-ray abnormalities consistent with active TBNo response to a course of antibiotics and/or symptomatic medicationsDecision by a medical officer to treat with anti-TB drugsAcceptable to start tx based on cxr findings with a compatible clinical presn even if smear negative
21 Extrapulmonary TBAt 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
22 Types of TB Cases New Relapse Failure Return after default (RAD) Transfer-inOther
23 Types of TB CasesNew- pt who has never had tx for TB or who has taken anti-TB drugs for < 1monthRelapse - pt. previously treated for TB, has been declared cured or tx completed, and is diagnosed with ( + ) smear or culture for TBFailure- pt while on tx is sputum smear ( + ) at 5 months or later during the course of tx
24 Types of TB CasesReturn after default A patient who returns to treatment with positive bacteriology (smear or culture), following interruption of treatment for months or more.Transfer-in- pt who has been transferred from another facility with proper referral slip to continue
25 Types of TB CasesOther1. 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.
26 Treatment RegimensEach standard drug is indicated by a capital letter. H- Isoniazid R- Rifampicin Z- Pyrazinamide E- Ethambutol S- Streptomycin
29 Treatment Regimens Regimen TB Patient Regimen III: 2HRZ/4HR New smear (-) but with minimal PTB on x-ray as confirmed by Medical OfficerNew extra-pulmonary TB (not serious)High resis if inh resis is > 4%; in phil-14.9% to 16.9% inh reis
30 Treatment of TB in Special Situations TB in pregnancy/lactationTB in pts with hepatic diseaseTB in pts with renal diseaseTB in the elderlyTB in HIV/AIDS
31 Tuberculosis in Pregnancy INH, Ethambutol & Rifampicin can be usedNot recommended: Pyrazinamide, Streptomycin, Kanamycin, CapreomycinStrep hazardous throughout- ototoxixity and fetal malformationConsensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)
32 TB treatment in Pregnancy Non-cavitary Disease -9HRECavitary Disease- 12HRETreat if symptomatic; If resistant to HR, may use Z after 1st trim; inadeq data on teratogenicityTB prophy - <35 yo, N cxr, (+)ppd, asx-delay until 3-6months postpartum except ppd>15 and no prev tx, >10 with high prev, with cxr inactive ptb; >5 mm in immunocomp; HIV+, recent converters, close contacts>35, ppd<15 – no tx unless immunocomp or close contacts; H hepatitis higher esp >35yoConsensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)
33 TB and Lactation Breast feeding not discouraged Anti-TB drug concentration - low, non-toxic & non-therapeutic in breast milkSupplemental pyridoxine to baby; if mother and baby both taking antiTB meds- do not breastfeed; 25MG/D VIT B6Consensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)
34 TB treatment & Liver Disease Hepatitis virus carriage or a past hx of acute hepatitis w/o clinical evidence of chronic liver diseaseRx- Usual short course chemotherapyestablished chronic liver disease2SHRE/6HR2SHE/10 HE
35 TB treatment & Liver Disease Hepatic failureStreptomycin & Ethambutol can be given.If a third drug is needed, Isoniazid or Rifampicin can be given cautiously in lowered dosesAcute Hepatitis – defer until hepatitis resolved or3SE/6HR
36 TB treatment & renal insufficiency/ renal failure Isoniazid, Rifampicin & Pyrazinamide can be given in normal dosages2HRZ/6HREtham 5-23mkd; pza mkd
37 Others TB in the Elderly TB in HIV + with susceptibility testing 9HRTB in HIV +with susceptibility testing2HRZE/4-7HRw/o susceptibility testingNon-cavitary- 9HRZECavitary -12HRZETb in elderly- harbor few bacilli that are resistant
38 Symptom-based approach to adverse effects of TB drugs Reassure the patientRifampicin3. Orange/redColored urineGive anti- histamineAny kind of drugs2. Mild skin reactionsGive medication at bedtime1. Gastro- intestinal intoleranceManagementDrugs responsibleSide-effects(Minor)
39 Pyridoxine (Vit B6) 100-200 mg for tx; 10mg for preventionIsoniazid5. Burning sensation of the feetWarm compress;Rotate sites of injectionStreptomycin4. Pain at injection siteManagementDrug(s) responsibleSide effects
40 AntipyreticsRifampicin7. Flu-like symptoms(fever, inflammation of the resp. tract)Aspirin or NSAIDAllopurinolPyrazinamide6. ArthralgiaManagementDrug(s) responsibleSide effects
41 Discontinue Anti-TB drugs Any kind of drugs (esp Strep)1. Severe skin rash due to hypersensitivityD/C anti-TB drugsIf sx subside, resume tx and monitorAny kind of drugs (esp Isoniazid, Rifampicin and Pyrazinamide2. Jaundice due to hepatitisManagementDrug(s) responsibleMajor side effects
42 Discontinue Ethambutol & refer to an opthalmologist 3. Impairment of visual acuity & color vision (optic neuritis)Discontinue StreptomycinStreptomycin4. Hearing impairment, tinnitus, vertigoManagementDrug(s) responsibleMajor side effects
43 Major side effectsDrug(s) responsibleManagement5. Oliguria or albuminuria due to renal disorderStreptomycinRifampicinDiscontinueStrep, Rifampicin6. Psychosis & convulsionIsoniazidDiscontinue Isoniazid7.Thrombo-cytopenia, anemia, shockDiscontinue Rifampicin