1. TUBERCULOSIS 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.

2. What is tuberculosis?
Tuberculosis is a disease caused by an infection with the bacteria Mycobacterium tuberculosis.

4. What are the symptoms? Typical signs of tuberculosis are:
Chronic or persistent cough and sputum production. If the disease is at an advanced stage the sputum will contain blood.
Fatigue.
Lack of appetite.
Weight loss.
Fever.
Night sweats.

5. How is tuberculosis treated?
Today, treatment involves three or four different kinds of antibiotics given in combination over 6 to 12 months.
Multiple medicines are necessary to prevent the emergence of resistance, which would lead to treatment failure.
The main cause of treatment failure is non-compliance with what is perceived as a demanding and prolonged programme of therapy.

6. TB TREATMENT PLAN
For positive culture do susceptibilities and report results to Health Department
begin taking four medications — isoniazid, rifampicin , ethambutol pyrazinamide and streptomycin .
The standard "short" course treatment for tuberculosis (TB), is:
isoniazid, rifampicin, pyrazinamide, and ethambutol for two months,
Then isoniazid and rifampicin alone for a further four months.
This regimen may change if tests later show some of these drugs to be ineffective.
This defines initial treatment.
The abbreviations are as follows: CDC = Centers for Disease Control and Prevention, ACET = Advisory Council for the Elimination of Tuberculosis, ATS = American Thoracic Society, INH = isoniazid, RIF = rifampin, PZA = pyrazinamide, EMB = ethambutol, SM = streptomycin, and DOT = directly observed therapy.
A study by Burman et al published in Chest July, 1997 addressed the cost of DOT versus self-administered therapy by pointing out that “despite a greater initial cost, DOT is a more cost-effective strategy because it achieves a higher cure rate after initial therapy, and thereby decreases treatment costs associated with failure of therapy and acquired drug resistance”.

7. ISONIAZID Adverse Reactions
Hepatitis
Peripheral neuropathy
Lupus
Hepatitis is a particular problem if doing mass PPD skin test screening and preventive therapy in low risk groups since there would be the probability of risking hepatitis in people with false positive PPD skin tests.

8. ISONIAZID Monitoring Liver function tests
Clinical signs of hepatic toxicity
Numbness/tingling of extremities
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9. ISONIAZID Drug Interactions
Alcohol
Phenytoin
Disulfiram
Aluminum Salts
Carbamazepine
Benzodiazepines
Anticoagulants
Ketoconazole
It is necessary to take a thorough medication history before initiating isoniazid therapy.

10. RIFAMPIN Adverse Reactions
Hepatitis
Orange discoloration of secretions
Drug interactions
Immunologic mediated illness
Be sure patient understands the orange coloration of secretions as this can be quite alarming to patients if they have not been forewarned. Immunologic mediated illness is a flu-like syndrome most prominent in people on twice a week dosing.

11. RIFAMPIN Monitoring Liver function tests
Clinical signs of hepatic toxicity
CBC, platelets, serum creatinine, bilirubin
Bleeding abnormalities
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12. RIFAMPIN Drug Interactions
Warfarin
Digoxin
Beta-blockers
Ketoconazole
Verapamil
Quinidine
Methadone
Phenytoin.
Corticosteroids
Oral Contraceptives
Dapsone
Theophylline
Sulfonylureas
Cyclosporine
Protease Inhibitors
It is necessary to take a thorough medication history before initiating rifampin therapy.
Note: The issue of protease inhibitors is discussed by Dr. Benator.

13. ETHAMBUTOL Adverse Reactions
Gout
Rash
Peripheral neuritis
Optic neuritis
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14. ETHAMBUTOL Monitoring
Visual acuity
Uric acid levels
Monitoring of visual acuity may best be accomplished thought education of the patient concerning ocular toxicity and to have the patient monitor their vision and report to the physician immediately any visual changes and stop the medication until they are reevaluated by the physician.

15. ETHAMBUTOL Drug Interaction
Aluminum salts
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16. PYRAZINAMIDE Adverse Reactions
Hepatitis
Gout
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17. PYRAZINAMIDE Monitoring
Liver function tests
Clinical signs of hepatic
toxicity
Uric acid levels
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18. STREPTOMYCIN Adverse Reactions
Auditory
Vestibular
Nephrotoxicity
Hypersensitivity
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19. STREPTOMYCIN Monitoring
Signs of Ototoxicity
Vertigo
Ataxia
Hearing Loss
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20. STREPTOMYCIN Drug Interactions
Loop diuretics
Neuromuscular blockers
Loop diuretics may enhanse the nephrotoxicity of streptomycin.
Streptomycin may escalate the effects of neuromuscular blockers and worsen the the condition of patients with certain neuromuscular diseases.