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TB Treatment Regimen Gina S. de los Reyes, M.D., FPCP, FPCCP.

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Presentation on theme: "TB Treatment Regimen Gina S. de los Reyes, M.D., FPCP, FPCCP."— Presentation transcript:

1 TB Treatment Regimen Gina S. de los Reyes, M.D., FPCP, FPCCP

2 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

3 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

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 lungs with the consequent complications. 4. To avoid relapse of the disease. 5. To prevent the devt of drug-resistant T.B (acquired resistance). 6. To protect his/her family and the community from infection.

5 A nti-TB drugs : Actions & Adverse Effects First line drugs Gastronal Cutaneous rxn Hepatitis BactericidalRifampicin Hepatitis Peripheral Neuropathy BactericidalIsoniazid Adverse Effects ActionDrug

6 Anti-TB drugs Ototoxicity Cutaneous Hypersen- sitivity BactericidalStreptomycin Hepatotoxicity Arthralgia BactericidalPyrazinamide Retrobulbar neuritis BacteriostaticEthambutol

7 Second-line drugs Ethionamide Prothionamide Sodium para- aminosalicylate (PAS) Cycloserine Ofloxacin Ciprofloxacin Capreomycin Kanamycin Viomycin Amikacin Co-amoxiclav Clarithromycin Rifamycin derivatives- Rifabutin, Rifapentene

8 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)

9 Drug Doses Pyrazinamide (28-30) (30-40) Ethambutol (15-20) (25-35) Streptomycin (12-18) (12-18)

10 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

11 FDCs For the patient: simplified drug intake Fewer pills to swallow Pills are identical Correct regimen is followed

12 FIXED DOSE COMBINATION: SIMPLER DOSE COMPUTATION Body Weight (kg)4-FDC (HRZE) 37 to 543 tablets 55 to 704 tablets > 705 tablets Practical dosing: 55 kg: 4 tablets daily

13 Short Course Chemotherapy 6 months regimen which includes Rifampicin and Pyrazinamide Standard Treatment- at least 12 months (w/o Rifampicin)

14 2 Phases of SCC Intensive phase- 2 months Continuation phase- 4 months

15 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

16 Objectives of SCC To achieve better bactericidal and sterilizing activities To prevent emergence of resistance

17 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 multiply NEVER GIVE A SINGLE DRUG (MONOTHERAPY)

18 Classification of TB Cases Pulmonary TB Smear (+) Smear (-) Extrapulmonary TB

19 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

20 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

21 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

22 Types of TB Cases New Relapse Failure Return after default (RAD) Transfer-in Other

23 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

24 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

25 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.

26 Each standard drug is indicated by a capital letter. H- Isoniazid R- Rifampicin Z- Pyrazinamide E- Ethambutol S- Streptomycin Treatment Regimens

27 RegimenTB Patient Regimen I 2HRZE/4HRE New pulmonary smear (+ ) cases New seriously ill pulmonary smear (-) cases with extensive parenchymal involvement New severely ill extra- pulmonary TB cases

28 Treatment Regimens RegimenTB Patient Regimen II: 2HRZES/ 1HRZE/5HRE Failure cases Relapse cases RAD (smear +) Other (smear +)

29 Treatment Regimens RegimenTB 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)

30 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

31 Tuberculosis in Pregnancy INH, Ethambutol & Rifampicin can be used Not recommended: Pyrazinamide, Streptomycin, Kanamycin, Capreomycin Consensus Statement ( Phil. Practice guidelines Group on Infectious Diseases)

32 TB treatment in Pregnancy Non-cavitary Disease - 9HRE Cavitary Disease- 12HRE Consensus 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 milk Consensus 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 disease Rx- Usual short course chemotherapy established chronic liver disease 2SHRE/6HR 2SHE/10 HE

35 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

36 TB treatment & renal insufficiency/ renal failure Isoniazid, Rifampicin & Pyrazinamide can be given in normal dosages 2HRZ/6HR

37 Others TB in the Elderly 9HR TB in HIV + with susceptibility testing 2HRZE/4-7HR w/o susceptibility testing Non-cavitary- 9HRZE Cavitary -12HRZE

38 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)

39 Pyridoxine (Vit B6) 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

40 Antipyretics Rifampicin 7. Flu-like symptoms (fever, inflammation of the resp. tract) Aspirin or NSAID Allopurinol Pyrazinamide6. Arthralgia ManagementDrug(s) responsible Side effects

41 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

42 Discontinue Ethambutol & refer to an opthalmologist Ethambutol 3. Impairment of visual acuity & color vision (optic neuritis) Discontinue Streptomycin Streptomycin4. Hearing impairment, tinnitus, vertigo ManagementDrug(s) responsible Major side effects

43 Drug(s) responsible Management 5. Oliguria or albuminuria due to renal disorder Streptomycin Rifampicin Discontinue Strep, Rifampicin 6. Psychosis & convulsion IsoniazidDiscontinue Isoniazid 7.Thrombo- cytopenia, anemia, shock RifampicinDiscontinue Rifampicin

44 Thank You for your kind attention!

45 2HRZE/4HR 2H 3 R 3 Z 3 E 3 /4H 3 R 3

46 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

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