Tuberculosis medical therapy special conditions: Difference between revisions

Jump to navigation Jump to search
 
(13 intermediate revisions by 4 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Tuberculosis}}
{{Tuberculosis}}
{{CMG}}; {{AE}} {{JS}}
{{CMG}}; {{AE}} {{Mashal Awais}}; {{JS}} {{Ammu}}


==Overview==
==Overview==
Medical therapy for tuberculosis in special conditions include [[HIV]] co-infection and extrapulmonary manifestations. Different approaches are taken for patients taking ART and those who do not take ART. Although WHO recommends the same drug regimen for pulmonary and extrapulmonary manifestations, various stages of skeletal tuberculosis are managed differently. For patients with [[renal]] or [[liver]] diseases, the first line of drugs are substituted with second-line drugs to prevent complications.


==HIV Coinfection==
==HIV Coinfection==
{{details|HIV coinfection with tuberculosis}}
Depending on the treatment status of each patient, different approaches may be taken:<ref name="pmid19105873">{{cite journal| author=Harries AD, Zachariah R, Lawn SD| title=Providing HIV care for co-infected tuberculosis patients: a perspective from sub-Saharan Africa. | journal=Int J Tuberc Lung Dis | year= 2009 | volume= 13 | issue= 1 | pages= 6-16 | pmid=19105873 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19105873  }} </ref>
Depending on the treatment status of each patient, different approaches may be taken:<ref name="pmid19105873">{{cite journal| author=Harries AD, Zachariah R, Lawn SD| title=Providing HIV care for co-infected tuberculosis patients: a perspective from sub-Saharan Africa. | journal=Int J Tuberc Lung Dis | year= 2009 | volume= 13 | issue= 1 | pages= 6-16 | pmid=19105873 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19105873  }} </ref>
===Patients Not Taking ART===
===Patients Not Taking ART===
* After the diagnosis of TB in [[HIV]]-positive patients, not taking [[antiretroviral therapy]] ([[ART]]), the priority is to initiate treatment for TB, along with [[co-trimoxazole]] and [[ART]].
 
* These patients should be treated with the same regimen as HIV-negative patients, with the exception that the optional 3 times/week of intensive phase treatment, is mandatory for HIV-positive patients.  This leads to a decrease in incidence of TB relapse and resistance to [[rifampicin]], often seen in HIV-positive patients.<ref name="pmid20353364">{{cite journal| author=Khan FA, Minion J, Pai M, Royce S, Burman W, Harries AD et al.| title=Treatment of active tuberculosis in HIV-coinfected patients: a systematic review and meta-analysis. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 9 | pages= 1288-99 | pmid=20353364 | doi=10.1086/651686 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20353364  }} </ref><ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref>
*After the diagnosis of TB in [[HIV]]-positive patients, not taking [[antiretroviral therapy]] ([[ART]]), the priority is to initiate treatment for TB, along with [[co-trimoxazole]] and [[ART]].
* The retreatment regimens are the same for HIV-positive and HIV-negative patients.
*These patients should be treated with the same regimen as HIV-negative patients, with the exception that the optional 3 times/week of intensive phase treatment, is mandatory for HIV-positive patients.  This leads to a decrease in incidence of TB relapse and resistance to [[rifampicin]], often seen in HIV-positive patients.<ref name="pmid20353364">{{cite journal| author=Khan FA, Minion J, Pai M, Royce S, Burman W, Harries AD et al.| title=Treatment of active tuberculosis in HIV-coinfected patients: a systematic review and meta-analysis. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 9 | pages= 1288-99 | pmid=20353364 | doi=10.1086/651686 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20353364  }} </ref><ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref>
*The retreatment regimens are the same for HIV-positive and HIV-negative patients.
 
According to the WHO, the following recommendations should be applied to these patients:<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref>
According to the WHO, the following recommendations should be applied to these patients:<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref>
*Patients with TB, who are known to be HIV-positive, and all TB patients who live in areas where HIV is prevalent, should be treated with at least the intensive phase of the TB treatment.
*Patients with TB, who are known to be HIV-positive, and all TB patients who live in areas where HIV is prevalent, should be treated with at least the intensive phase of the TB treatment.


*During the continuation phase of the treatment, these patients should also receive a daily dose.
*During the continuation phase of the treatment, these patients should also receive a daily dose.


*In the impossibility of taking the daily dose, a continuation phase of 3 times/week is acceptable.  Regarding the duration of therapy, some experts recommend prolongation of TB treatment in certain [[HIV]]-positive patients.<ref name=MMWR>{{cite web | title = Treatment of tuberculosis | url = http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm }}</ref>
*In the impossibility of taking the daily dose, a continuation phase of 3 times/week is acceptable.  Regarding the duration of therapy, some experts recommend prolongation of TB treatment in certain [[HIV]]-positive patients.<ref name="MMWR">{{cite web | title = Treatment of tuberculosis | url = http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm }}</ref>
*[[HIV]]-positive patients with TB should receive TB treatment, as least for the same period of time as HIV-negative patients.''
*[[HIV]]-positive patients with TB should receive TB treatment, at least for the same period of time as HIV-negative patients.


===Patients Taking ART===
===Patients Taking ART===
Besides improving the survival rate of HIV-positive patients,
Besides improving the survival rate of HIV-positive patients, antiretroviral therapy can decrease TB rates by about 90% at the individual level, 60% population level, and 50% reduction in recurrence rates. People with active TB and HIV must be initiated with ART irrespective of CD4 cell count. By the first 8 weeks of starting TB treatment, ART must be initiated to reduce the complications.
 
<!--
 
Antiretroviral therapy improves survival in HIV-positive patients (16). In addition, antiretroviral therapy reduces TB rates by up to 90% at an individual level, by 60% at a population level and it reduces TB recurrence rates by 50% (21–22). ART should be initiated for all people living with HIV with active TB disease irrespective of CD4 cell count. TB treatment should be started first, followed by ART as soon as possible and within the first 8 weeks of starting TB treatment (23).  


-->
===Co-trimoxazole===
===Co-trimoxazole===
Preventive therapy with [[co-trimoxazole]] should be initiated as early as possible in all TB patients who are HIV-positive, and should be continued during the entire treatment of TB.  Co-trimoxazol reduces the mortality rate of HIV-positive tuberculous patients, as well as infections by ''[[Pneumocystis jirovecii]]'' and [[malaria]].  After TB treatment has been complete, continuation of co-trimoxazol should be evaluated according to each country's guidelines.<ref name="pmid19105873">{{cite journal| author=Harries AD, Zachariah R, Lawn SD| title=Providing HIV care for co-infected tuberculosis patients: a perspective from sub-Saharan Africa. | journal=Int J Tuberc Lung Dis | year= 2009 | volume= 13 | issue= 1 | pages= 6-16 | pmid=19105873 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19105873  }} </ref><ref name=WHO>{{cite web | title = Co-trimoxazole prophylaxis | url = http://www.who.int/hiv/pub/guidelines/ctx/en/ }}</ref>
Preventive therapy with [[co-trimoxazole]] should be initiated as early as possible in all TB patients who are HIV-positive, and should be continued during the entire treatment of TB.  Co-trimoxazol reduces the mortality rate of HIV-positive tuberculous patients, as well as infections by ''[[Pneumocystis jirovecii]]'' and [[malaria]].  After TB treatment has been complete, continuation of co-trimoxazol should be evaluated according to each country's guidelines.<ref name="pmid19105873">{{cite journal| author=Harries AD, Zachariah R, Lawn SD| title=Providing HIV care for co-infected tuberculosis patients: a perspective from sub-Saharan Africa. | journal=Int J Tuberc Lung Dis | year= 2009 | volume= 13 | issue= 1 | pages= 6-16 | pmid=19105873 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19105873  }} </ref><ref name="WHO">{{cite web | title = Co-trimoxazole prophylaxis | url = http://www.who.int/hiv/pub/guidelines/ctx/en/ }}</ref>


==Extrapulmonary==
==Extrapulmonary==
===Tuberculous Lymphadenitis===
===Tuberculous Lymphadenitis===


The infectious disease society of America(IDSA) recommends treatment for 6 months for drug susceptible organism.
The infectious disease society of America(IDSA) recommends treatment for 6 months for the drug-susceptible organisms.


*The regimen includes [[isoniazid]], [[rifampin]], [[pyrazinamide]] and [[ethambutol]] for 2 months followed by [[isoniazid]] and [[rifampin]] for another 4 months.
*The regimen includes [[isoniazid]], [[rifampin]], [[pyrazinamide]] and [[ethambutol]] for 2 months followed by [[isoniazid]] and [[rifampin]] for another 4 months.
*Surgical excision as an adjuvant to antibiotic therapy for TB lymphadenitis caused by drug resistant organism.
*Surgical excision as an adjuvant to antibiotic therapy for TB lymphadenitis caused by the drug-resistant organism.


Studies have shown that [[steroids]] used for local discomfort and adjuvant [[immunotherapy]] with [[anti tumor necrosis factor]] agents can be beneficial but no specific recommendation has been made. <ref name=NCBI>{{cite web | title = Oxford journal TB lymphadenitis| url = http://cid.oxfordjournals.org/content/53/6/555.long}}</ref>
Studies have shown that [[steroids]] used for local discomfort and adjuvant [[immunotherapy]] with [[anti tumor necrosis factor]] agents can be beneficial but no specific recommendation has been made. <ref name="NCBI">{{cite web | title = Oxford journal TB lymphadenitis| url = http://cid.oxfordjournals.org/content/53/6/555.long}}</ref>


===Skeletal Tuberculosis===
===Skeletal Tuberculosis===


The main stay of treatment for skeletal tuberculosis is antibiotics and surgery. The selection of antibiotics for skeletal tuberculosis is the same as that of pulmonary tuberculosis.
The mainstay of treatment for skeletal tuberculosis is antibiotics and surgery. The selection of [[antibiotics]] for skeletal tuberculosis is the same as that of pulmonary tuberculosis. <ref name="Tuberculosis">{{cite web | title = tech ortho TB| url = http://www.global-help.org/publications/articles/techortho_tuberculosismusculoskeletal.pdf }}</ref>


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|valign=top|
| valign="top" |
|+
|+
! style="background: #4479BA; width: 250px;" | {{fontcolor|#FFF|Stage}}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Stage}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Treatment}}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Treatment}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Stage 1 (synovitis)
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Stage 1 (synovitis)
| style="padding: 5px 5px; background: #F5F5F5;" |<br>&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Rest<br>&nbsp;&nbsp;&nbsp;Restriction of movements<br>&nbsp;&nbsp;&nbsp;Splinting
| style="padding: 5px 5px; background: #F5F5F5;" |&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Rest<br>&nbsp;&nbsp;&nbsp;Restriction of movements<br>&nbsp;&nbsp;&nbsp;Splinting
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 2 (Early arthritis)
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 2 (Early arthritis)
| style="padding: 5px 5px; background: #F5F5F5;" |<br>&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Rest<br>&nbsp;&nbsp;&nbsp;Restriction of movements<br>&nbsp;&nbsp;&nbsp;Splinting<br>&nbsp;&nbsp;&nbsp;Synovectomy
| style="padding: 5px 5px; background: #F5F5F5;" |&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Rest<br>&nbsp;&nbsp;&nbsp;Restriction of movements<br>&nbsp;&nbsp;&nbsp;Splinting<br>&nbsp;&nbsp;&nbsp;Synovectomy
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 3 (Advanced arthritis)
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 3 (Advanced arthritis)
| style="padding: 5px 5px; background: #F5F5F5;|<br>&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Osteotomy<br>&nbsp;&nbsp;&nbsp;Arthrodesis<br>&nbsp;&nbsp;&nbsp;Arthroplasty
| style="padding: 5px 5px; background: #F5F5F5;" |&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Osteotomy<br>&nbsp;&nbsp;&nbsp;Arthrodesis<br>&nbsp;&nbsp;&nbsp;Arthroplasty
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 4 (Advanced arthritis)
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 4 (Advanced arthritis)
| style="padding: 5px 5px; background: #F5F5F5;"|<br>&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Osteotomy<br>&nbsp;&nbsp;&nbsp;Arthrodesis<br>&nbsp;&nbsp;&nbsp;Arthroplasty
| style="padding: 5px 5px; background: #F5F5F5;" |&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Osteotomy<br>&nbsp;&nbsp;&nbsp;Arthrodesis<br>&nbsp;&nbsp;&nbsp;Arthroplasty
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 5
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 5
| style="padding: 5px 5px; background: #F5F5F5;"|<br>&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Osteotomy<br>&nbsp;&nbsp;&nbsp;Arthrodesis<br>&nbsp;&nbsp;&nbsp;Arthroplasty
| style="padding: 5px 5px; background: #F5F5F5;" |&nbsp;&nbsp;&nbsp;Chemotherapy<br>&nbsp;&nbsp;&nbsp;Osteotomy<br>&nbsp;&nbsp;&nbsp;Arthrodesis<br>&nbsp;&nbsp;&nbsp;Arthroplasty
|}
|}


===Tuberculous Meningitis===
===Tuberculous Meningitis===


The treatment of TB meningitis is 2 months of isoniazid, ethambutol, pyrazinamide and rifampicin, followed by rifampicin and isoniazid alone for a further ten months. Steroids help reduce the risk of death or disabling neurological deficit.[6] Steroids can be used in the first six weeks of treatment, but must be used with caution in individuals who also have HIV.<ref name="pmid18254003">{{cite journal| author=Prasad K, Singh MB| title=Corticosteroids for managing tuberculous meningitis. | journal=Cochrane Database Syst Rev | year= 2008 | volume=  | issue= 1 | pages= CD002244 | pmid=18254003 | doi=10.1002/14651858.CD002244.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18254003  }} </ref> A few patients may require immunomodulatory agents such as thalidomide. Treatment must be started as soon as there is a reasonable suspicion of the diagnosis. Treatment must not be delayed while waiting for confirmation of the diagnosis. Hydrocephalus occurs as a complication in about a third of patients with TB meningitis and will require a ventricular shunt. Aspirin may be used as anadjuvant therapy to reduce complications.<ref name="pmid20421121">{{cite journal| author=Misra UK, Kalita J, Nair PP| title=Role of aspirin in tuberculous meningitis: a randomized open label placebo controlled trial. | journal=J Neurol Sci | year= 2010 | volume= 293 | issue= 1-2 | pages= 12-7 | pmid=20421121 | doi=10.1016/j.jns.2010.03.025 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20421121  }} </ref> BCG vaccination has been proved to prevent tuberculous meningitis.
The treatment of TB meningitis is 2 months of isoniazid, ethambutol, pyrazinamide, and rifampicin, followed by rifampicin and isoniazid alone for a further ten months. Steroids help reduce the risk of death or disabling neurological deficit.[6] Steroids can be used in the first six weeks of treatment, but must be used with caution in individuals who also have HIV.<ref name="pmid18254003">{{cite journal| author=Prasad K, Singh MB| title=Corticosteroids for managing tuberculous meningitis. | journal=Cochrane Database Syst Rev | year= 2008 | volume=  | issue= 1 | pages= CD002244 | pmid=18254003 | doi=10.1002/14651858.CD002244.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18254003  }} </ref> A few patients may require immunomodulatory agents such as thalidomide. Treatment must be started as soon as there is a reasonable suspicion of the diagnosis. Treatment must not be delayed while waiting for confirmation of the diagnosis. Hydrocephalus occurs as a complication in about a third of patients with TB meningitis and will require a ventricular shunt. Aspirin may be used as an adjuvant therapy to reduce complications.<ref name="pmid20421121">{{cite journal| author=Misra UK, Kalita J, Nair PP| title=Role of aspirin in tuberculous meningitis: a randomized open-label placebo-controlled trial. | journal=J Neurol Sci | year= 2010 | volume= 293 | issue= 1-2 | pages= 12-7 | pmid=20421121 | doi=10.1016/j.jns.2010.03.025 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20421121  }} </ref> BCG vaccination has been proved to prevent tuberculous meningitis.


===Miliary Tuberculosis===
===Miliary Tuberculosis===
Miliary tuberculosis is a grave condition which must be treated immediately. A delay in treatment may cause serious complications and even death. 8-9 months is the time of treatment for susceptible organism. Treatment of miliary tuberculosis includes 6 months of daily or intermittent treatment. <ref name="pmid22771605">{{cite journal| author=Sharma SK, Mohan A, Sharma A| title=Challenges in the diagnosis & treatment of miliary tuberculosis. | journal=Indian J Med Res | year= 2012 | volume= 135 | issue= 5 | pages= 703-30 | pmid=22771605 | doi= | pmc=PMC3401706 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22771605  }} </ref>. Expert opinion suggests that corticosteroid therapy may be useful for treating respiratory failure caused by disseminated tuberculosis but there are no data to support its use.
Miliary tuberculosis is a grave condition that must be treated immediately. A delay in treatment may cause serious complications and even death. 8-9 months is the time of treatment for the susceptible organisms. Treatment of miliary tuberculosis includes 6 months of daily or intermittent treatment. <ref name="pmid22771605">{{cite journal| author=Sharma SK, Mohan A, Sharma A| title=Challenges in the diagnosis & treatment of miliary tuberculosis. | journal=Indian J Med Res | year= 2012 | volume= 135 | issue= 5 | pages= 703-30 | pmid=22771605 | doi= | pmc=PMC3401706 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22771605  }} </ref>. Expert opinion suggests that corticosteroid therapy may be useful for treating respiratory failure caused by disseminated tuberculosis but there are no data to support its use.


===Tuberculosis Peritonitis===
===Tuberculosis Peritonitis===
Medical therapy for tuberculous peritonitis involves the multi drug regimen of tuberculosis consisting of 5 major drugs as the first line of treatment including [[isoniazid]], [[ethambutol]], [[pyrazinamide]], [[streptomycin]] and [[rifamppicin]]. Corticosteroids can be added to the treatment to reduce the complications. Response to treatment is manifested as disappearance of ascitis and  resolution of symptoms . All lab based values return to normal baseline within 3 months of treatment initiation. <ref name="pmid16197489">{{cite journal| author=Sanai FM, Bzeizi KI| title=Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment. | journal=Aliment Pharmacol Ther | year= 2005 | volume= 22 | issue= 8 | pages= 685-700 | pmid=16197489 | doi=10.1111/j.1365-2036.2005.02645.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16197489  }} </ref>.


===Tuberculous Pericarditis===
===Tuberculous Pericarditis===


A 2 months course of [[isoniazid]], [[pyrazinamide]], [[rifampicin]], and [[ethambutol]] followed by 4 months course of [[isoniazid]] and [[rifampicin]] is shown to be effective <ref name="pmidpmid2106816">{{cite journal| author=Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbaro JA| title=A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen. | journal=Ann Intern Med | year= 1990 | volume= 112 | issue= 6 | pages= 407-15 | pmid=pmid2106816 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2106816  }} </ref>. For patients with pericardial tuberculosis, a 6-month regimen is recommended. [[Corticosteroids]] are recommended as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of antituberculosis therapy. In a randomized, double-blind, controlled trial, patients in the later effusive--constrictive phase who received [[prednisolone]] had a significantly more rapid clinical resolution compared with patients given placebo. [[Prednisolone]] did not reduce the risk of constrictive pericarditis. It is recommended that daily adjunctive [[prednisolone]] or prednisone alone treatment be given to adults and children with tuberculous pericarditis. Following are the dosage recommendations:
A 2 months course of [[isoniazid]], [[pyrazinamide]], [[rifampicin]], and [[ethambutol]] followed by 4 months course of [[isoniazid]] and [[rifampicin]] is shown to be effective <ref name="pmidpmid2106816">{{cite journal| author=Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbaro JA| title=A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen. | journal=Ann Intern Med | year= 1990 | volume= 112 | issue= 6 | pages= 407-15 | pmid=pmid2106816 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2106816  }} </ref>. For patients with pericardial tuberculosis, a 6-month regimen is recommended. [[Corticosteroids]] is recommended as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of antituberculosis therapy. In a randomized, double-blind, controlled trial, patients in the later effusive--constrictive phase who received [[prednisolone]] had a significantly more rapid clinical resolution compared with patients given a placebo. [[Prednisolone]] did not reduce the risk of constrictive pericarditis. It is recommended that daily adjunctive [[prednisolone]] or prednisone alone treatment be given to adults and children with tuberculous pericarditis. Following are the dosage recommendations:
 
*Adults:  [[Prednisone]] 60 mg/day  given for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and finally 5 mg/day for week 11 (the final week)
*Adults:  [[Prednisone]] 60 mg/day  given for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and finally 5 mg/day for week 11 (the final week)
*Children: Doses should be proportionate to their weight, beginning with about 1 mg/kg body weight and decreasing the dose as described for adults.<ref name="pmidpmid12836625">{{cite journal| author=American Thoracic Society. CDC. Infectious Diseases Society of America| title=Treatment of tuberculosis. | journal=MMWR Recomm Rep | year= 2003 | volume= 52 | issue= RR-11 | pages= 1-77 | pmid=pmid12836625 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12836625  }} </ref>
*Children: Doses should be proportionate to their weight, beginning with about 1 mg/kg body weight and decreasing the dose as described for adults.<ref name="pmidpmid12836625">{{cite journal| author=American Thoracic Society. CDC. Infectious Diseases Society of America| title=Treatment of tuberculosis. | journal=MMWR Recomm Rep | year= 2003 | volume= 52 | issue= RR-11 | pages= 1-77 | pmid=pmid12836625 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12836625  }} </ref>


===Renal Tuberculosis===
===Renal Tuberculosis===
<!--
Drug regimen is similar to other types of tuberculosis with a multidrug antibiotic therapy with antitubercular drugs.
According to the 4th edition of WHO recommendations;
According to the 4th edition of WHO recommendations;
:*Pulmonary and extrapulmonary disease should be treated with the same regimens.
:*Pulmonary and extrapulmonary disease should be treated with the same regimens.
:*Continuation phase for 6-9 months regimens that include [[INH]] and [[RIF]] are highly recommended.  
:*Continuation phase for 6-9 months regimens that include [[INH]] and [[RIF]] are highly recommended.
:*Prolongation of therapy also should be considered for patients with tuberculosis in any site that is slow to respond.  
:*Prolongation of therapy also should be considered for patients with tuberculosis in any site that is slow to respond.
:*The addition of [[corticosteroid]]s is recommended for patients with tuberculous pericarditis and tuberculous meningitis.
:*The addition of [[corticosteroid]]s is recommended for patients with tuberculous pericarditis and tuberculous meningitis.
:*In tuberculous meningitis, ethambutol should be replaced by streptomycin.
:*In tuberculous meningitis, ethambutol should be replaced by streptomycin.
{|
{|
|-
|-
| valign=top |
| valign="top" |
{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:35em" cellpadding="2" cellspacing="0";
{| style="border: 0px; font-size: 90%; margin: 3px; width: 500px;" align="center"
! style="padding: 0 5px; font-size: 100%; background: #A5B2D6" align=center | ''{{fontcolor|#000000|Statandard Regimens For New TB Patients With Drug-Susceptible TB}}''
! style="padding: 0 5px; font-size: 100%; background: #4479BA" align="center" |''{{fontcolor|#FFF|Statandard Regimens For New TB Patients With Drug-Susceptible TB}}''
|-
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=left | ''{{fontcolor|#6C7B8B|Intensive Initial Phase}}''
| style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align="left" |'''''Intensive Initial Phase'''''
|-
|-
| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" | ▸ '''''Initial Phase''''': 2 months of '''HRZS''' <sup>†</sup>
| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" |▸ '''''Initial Phase''''': 2 months of '''HRZS''' <sup>†</sup>
|-
|-
! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=left | ''{{fontcolor|#6C7B8B|Continuation phase}}''
| style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align="left" |'''''Continuation phase'''''
|-
|-
| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" | ▸ '''''Continuation Phase''''': 6-9 months <sup>‡</sup> of '''HR'''
| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" |▸ '''''Continuation Phase''''': 6-9 months <sup>‡</sup> of '''HR'''
|-
|-
| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" |<small>‡ In this group decisions to prolong the continuation phase should be made on an individual basis.</small>
|}
|}
|}
|}
‡ In this group decisions to prolong the continuation phase should be made on an individual basis.


====Renal Insufficiency and End-Stage Renal Disease====
====Renal Insufficiency and End-Stage Renal Disease====
For patients undergoing [[hemodialysis]], administration of all drugs after [[dialysis]] is preferred to facilitate DOT and to avoid premature removal of drugs such as [[PZA]] and [[cycloserine]]. To avoid toxicity it is important to monitor serum drug concentrations in persons with [[renal failure]] who are taking cycloserine or [[EMB]]. There is little information concerning the effects of peritoneal dialysis on clearance of antituberculosis drugs.
For patients undergoing [[hemodialysis]], administration of all drugs after [[dialysis]] is preferred to facilitate DOT and to avoid premature removal of drugs such as [[PZA]] and [[cycloserine]]. To avoid toxicity it is important to monitor serum drug concentrations in persons with [[renal failure]] who are taking cycloserine or [[EMB]]. There is little information concerning the effects of peritoneal dialysis on the clearance of antituberculosis drugs.
 
-->
 


==Liver Disease==
==Liver Disease==
<!--
[[INH]], [[RIF]], and [[PZA]] all can cause hepatitis that may result in additional [[liver]] damage in patients with preexisting liver disease. However, because of the effectiveness of these drugs (particularly INH and RIF), they should be used if at all possible, even in the presence of preexisting liver disease. If serum [[AST]] is more than three times normal before the initiation of treatment (and the abnormalities are not thought to be caused by tuberculosis), several treatment options exist. One option is to treat with RIF, EMB, and PZA for 6 months, avoiding INH. A second option is to treat with INH and RIF for 9 months, supplemented by EMB until INH and RIF susceptibility are demonstrated, thereby avoiding PZA. For patients with severe liver disease a regimen with only one hepatotoxic agent, generally RIF plus EMB, could be given for 12 months, preferably with another agent, such as a [[fluoroquinolone]], for the first 2 months; however, there are no data to support this recommendation.  
[[INH]], [[RIF]], and [[PZA]] all can cause hepatitis that may result in additional [[liver]] damage in patients with preexisting liver disease. However, because of the effectiveness of these drugs (particularly INH and RIF), they should be used if at all possible, even in the presence of preexisting liver disease. If serum [[AST]] is more than three times normal before the initiation of treatment (and the abnormalities are not thought to be caused by tuberculosis), several treatment options exist. One option is to treat with RIF, EMB, and PZA for 6 months, avoiding INH. A second option is to treat with INH and RIF for 9 months, supplemented by EMB until INH and RIF susceptibility are demonstrated, thereby avoiding PZA. For patients with severe liver disease a regimen with only one hepatotoxic agent, generally RIF plus EMB, could be given for 12 months, preferably with another agent, such as a [[fluoroquinolone]], for the first 2 months; however, there are no data to support this recommendation.  


In all patients with preexisting liver disease, frequent clinical and laboratory monitoring should be performed to detect drug-induced [[hepatic]] injury.
In all patients with preexisting liver disease, frequent clinical and laboratory monitoring should be performed to detect drug-induced [[hepatic]] injury.


-->
==Hepatitis and Anti-TB medications==
 
WHO Recommendation for Anti-TB drug-induced hepatitis is:
 
:*If TB treatment has been stopped, Wait for liver function tests to normalize and resolution of the clinical symptoms (nausea, abdominal pain) before reintroducing the anti-TB drugs.
:*If the liver function tests are not available, it is advisable to wait for extra 2 weeks after resolution of jaundice and upper abdominal tenderness before restarting TB treatment.
:*If the signs and symptoms do not resolve and the liver disease is severe, the non-hepatotoxic regimen consisting of streptomycin, ethambutol and a fluoroquinolone should be started (or continued) for a total of 18-24 months.<ref name="-2003">{{Cite journal  | title = Treatment of tuberculosis.|journal = MMWR Recomm Rep | volume = 52 | issue = RR-11 | pages = 1-77 |month = Jun | year = 2003 | doi =  | PMID = 12836625 }}</ref>
:*Reintroducing one drug at a time is the optimal approach, especially if the patient’s hepatitis was severe.
:*Once drug-induced hepatitis has resolved, the drugs are reintroduced one at a time. But if symptoms recur or liver function tests become abnormal again as the drugs are reintroduced, the last drug added should be stopped.
:*Some advise starting with rifampicin because it is less likely than isoniazid or pyrazinamide to cause hepatotoxicity and is the most effective agent .<ref name="-2003">{{Cite journal  | title = Treatment of tuberculosis. | journal = MMWR Recomm Rep | volume = 52 | issue = RR-11 | pages = 1-77 | month = Jun | year = 2003 | doi =  | PMID = 12836625 }}</ref> <ref name="Saukkonen-2006">{{Cite journal  | last1 = Saukkonen | first1 = JJ.|last2 = Cohn | first2 = DL. | last3 = Jasmer | first3 = RM. | last4 = Schenker | first4 = S. | last5 = Jereb | first5 = JA. | last6 = Nolan | first6 = CM. | last7 = Peloquin | first7 = CA. | last8 = Gordin | first8 = FM. | last9 = Nunes | first9 = D. | title = An official ATS statement: hepatotoxicity of antituberculosis therapy. | journal = Am J Respir Crit Care Med | volume = 174 | issue = 8 | pages = 935-52 | month = Oct | year = 2006 | doi = 10.1164/rccm.200510-1666ST | PMID = 17021358 }}</ref> After 3–7 days, isoniazid may be reintroduced. In patients who have experienced jaundice but tolerate the reintroduction of rifampicin and isoniazid, it is advisable to avoid pyrazinamide.
 
===Alternative regimens in Anti-TB induced Hepatitis===
It depends on which drug is implicated as the cause of hepatitis.
 
:*If rifampicin is implicated, a suggested regimen without rifampicin is '''2 months''' of [[Isoniazid]], [[Ethambutol]] and [[Streptomycin]]followed by '''10 months''' of [[Isoniazid]] and [[Ethambutol]].
:*If [[Isoniazid]] cannot be used, '''6-9 months''' of [[Rifampicin]], [[Pyrazinamide]] and [[Ethambutol]] can be considered.
:*If [[Pyrazinamide]] is discontinued before the patient has completed the intensive phase, the total duration of isoniazid and rifampicin therapy may be extended to '''9 months'''.<ref name="-2003">{{Cite journal  | title = Treatment of tuberculosis. | journal = MMWR Recomm Rep | volume = 52|issue = RR-11 | pages = 1-77 | month = Jun | year = 2003 | doi =  | PMID = 12836625 }}</ref>
:*If neither isoniazid nor rifampicin can be used, the non-hepatotoxic regimen consisting of [[Streptomycin]], [[ethambutol]] and a[[fluoroquinolone]] should be continued for a total of '''18-24 months'''.
:*Hepatitis during the intensive phase of TB treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol: once hepatitis has resolved, restart the same drugs '''EXCEPT''' <u>replace</u> pyrazinamide with streptomycin to '''complete the 2-month course''' of initial therapy, followed by [[Rifampicin]] and  [[Isoniazid]] for the 6-month continuation phase.
:*Hepatitis during the continuation phase: once hepatitis has resolved, '''restart''' [[Isoniazid]] and [[Rifampicin]] to '''complete the 4-month continuation'''phase of therapy.
 
==Referencies==
==Referencies==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category: Pulmonology]]
[[Category:Pulmonology]]
[[Category:Primary care]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
{{WH}}
{{WS}}

Latest revision as of 03:22, 25 February 2021

Tuberculosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Tuberculosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Children

HIV Coinfection

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Special Conditions
Drug-resistant

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Tuberculosis medical therapy special conditions On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Tuberculosis medical therapy special conditions

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Tuberculosis medical therapy special conditions

CDC on Tuberculosis medical therapy special conditions

Tuberculosis medical therapy special conditions in the news

Blogs on Tuberculosis medical therapy special conditions

Directions to Hospitals Treating Tuberculosis

Risk calculators and risk factors for Tuberculosis medical therapy special conditions

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mashal Awais, M.D.[2]; João André Alves Silva, M.D. [3] Ammu Susheela, M.D. [4]

Overview

Medical therapy for tuberculosis in special conditions include HIV co-infection and extrapulmonary manifestations. Different approaches are taken for patients taking ART and those who do not take ART. Although WHO recommends the same drug regimen for pulmonary and extrapulmonary manifestations, various stages of skeletal tuberculosis are managed differently. For patients with renal or liver diseases, the first line of drugs are substituted with second-line drugs to prevent complications.

HIV Coinfection

Depending on the treatment status of each patient, different approaches may be taken:[1]

Patients Not Taking ART

  • After the diagnosis of TB in HIV-positive patients, not taking antiretroviral therapy (ART), the priority is to initiate treatment for TB, along with co-trimoxazole and ART.
  • These patients should be treated with the same regimen as HIV-negative patients, with the exception that the optional 3 times/week of intensive phase treatment, is mandatory for HIV-positive patients. This leads to a decrease in incidence of TB relapse and resistance to rifampicin, often seen in HIV-positive patients.[2][3]
  • The retreatment regimens are the same for HIV-positive and HIV-negative patients.

According to the WHO, the following recommendations should be applied to these patients:[3]

  • Patients with TB, who are known to be HIV-positive, and all TB patients who live in areas where HIV is prevalent, should be treated with at least the intensive phase of the TB treatment.
  • During the continuation phase of the treatment, these patients should also receive a daily dose.
  • In the impossibility of taking the daily dose, a continuation phase of 3 times/week is acceptable. Regarding the duration of therapy, some experts recommend prolongation of TB treatment in certain HIV-positive patients.[4]
  • HIV-positive patients with TB should receive TB treatment, at least for the same period of time as HIV-negative patients.

Patients Taking ART

Besides improving the survival rate of HIV-positive patients, antiretroviral therapy can decrease TB rates by about 90% at the individual level, 60% population level, and 50% reduction in recurrence rates. People with active TB and HIV must be initiated with ART irrespective of CD4 cell count. By the first 8 weeks of starting TB treatment, ART must be initiated to reduce the complications.

Co-trimoxazole

Preventive therapy with co-trimoxazole should be initiated as early as possible in all TB patients who are HIV-positive, and should be continued during the entire treatment of TB. Co-trimoxazol reduces the mortality rate of HIV-positive tuberculous patients, as well as infections by Pneumocystis jirovecii and malaria. After TB treatment has been complete, continuation of co-trimoxazol should be evaluated according to each country's guidelines.[1][5]

Extrapulmonary

Tuberculous Lymphadenitis

The infectious disease society of America(IDSA) recommends treatment for 6 months for the drug-susceptible organisms.

Studies have shown that steroids used for local discomfort and adjuvant immunotherapy with anti tumor necrosis factor agents can be beneficial but no specific recommendation has been made. [6]

Skeletal Tuberculosis

The mainstay of treatment for skeletal tuberculosis is antibiotics and surgery. The selection of antibiotics for skeletal tuberculosis is the same as that of pulmonary tuberculosis. [7]

Stage Treatment
Stage 1 (synovitis)    Chemotherapy
   Rest
   Restriction of movements
   Splinting
Stage 2 (Early arthritis)    Chemotherapy
   Rest
   Restriction of movements
   Splinting
   Synovectomy
Stage 3 (Advanced arthritis)    Chemotherapy
   Osteotomy
   Arthrodesis
   Arthroplasty
Stage 4 (Advanced arthritis)    Chemotherapy
   Osteotomy
   Arthrodesis
   Arthroplasty
Stage 5    Chemotherapy
   Osteotomy
   Arthrodesis
   Arthroplasty

Tuberculous Meningitis

The treatment of TB meningitis is 2 months of isoniazid, ethambutol, pyrazinamide, and rifampicin, followed by rifampicin and isoniazid alone for a further ten months. Steroids help reduce the risk of death or disabling neurological deficit.[6] Steroids can be used in the first six weeks of treatment, but must be used with caution in individuals who also have HIV.[8] A few patients may require immunomodulatory agents such as thalidomide. Treatment must be started as soon as there is a reasonable suspicion of the diagnosis. Treatment must not be delayed while waiting for confirmation of the diagnosis. Hydrocephalus occurs as a complication in about a third of patients with TB meningitis and will require a ventricular shunt. Aspirin may be used as an adjuvant therapy to reduce complications.[9] BCG vaccination has been proved to prevent tuberculous meningitis.

Miliary Tuberculosis

Miliary tuberculosis is a grave condition that must be treated immediately. A delay in treatment may cause serious complications and even death. 8-9 months is the time of treatment for the susceptible organisms. Treatment of miliary tuberculosis includes 6 months of daily or intermittent treatment. [10]. Expert opinion suggests that corticosteroid therapy may be useful for treating respiratory failure caused by disseminated tuberculosis but there are no data to support its use.

Tuberculosis Peritonitis

Medical therapy for tuberculous peritonitis involves the multi drug regimen of tuberculosis consisting of 5 major drugs as the first line of treatment including isoniazid, ethambutol, pyrazinamide, streptomycin and rifamppicin. Corticosteroids can be added to the treatment to reduce the complications. Response to treatment is manifested as disappearance of ascitis and resolution of symptoms . All lab based values return to normal baseline within 3 months of treatment initiation. [11].

Tuberculous Pericarditis

A 2 months course of isoniazid, pyrazinamide, rifampicin, and ethambutol followed by 4 months course of isoniazid and rifampicin is shown to be effective [12]. For patients with pericardial tuberculosis, a 6-month regimen is recommended. Corticosteroids is recommended as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of antituberculosis therapy. In a randomized, double-blind, controlled trial, patients in the later effusive--constrictive phase who received prednisolone had a significantly more rapid clinical resolution compared with patients given a placebo. Prednisolone did not reduce the risk of constrictive pericarditis. It is recommended that daily adjunctive prednisolone or prednisone alone treatment be given to adults and children with tuberculous pericarditis. Following are the dosage recommendations:

  • Adults: Prednisone 60 mg/day given for 4 weeks, followed by 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and finally 5 mg/day for week 11 (the final week)
  • Children: Doses should be proportionate to their weight, beginning with about 1 mg/kg body weight and decreasing the dose as described for adults.[13]

Renal Tuberculosis

Drug regimen is similar to other types of tuberculosis with a multidrug antibiotic therapy with antitubercular drugs. According to the 4th edition of WHO recommendations;

  • Pulmonary and extrapulmonary disease should be treated with the same regimens.
  • Continuation phase for 6-9 months regimens that include INH and RIF are highly recommended.
  • Prolongation of therapy also should be considered for patients with tuberculosis in any site that is slow to respond.
  • The addition of corticosteroids is recommended for patients with tuberculous pericarditis and tuberculous meningitis.
  • In tuberculous meningitis, ethambutol should be replaced by streptomycin.
Statandard Regimens For New TB Patients With Drug-Susceptible TB
Intensive Initial Phase
Initial Phase: 2 months of HRZS
Continuation phase
Continuation Phase: 6-9 months of HR
‡ In this group decisions to prolong the continuation phase should be made on an individual basis.

Renal Insufficiency and End-Stage Renal Disease

For patients undergoing hemodialysis, administration of all drugs after dialysis is preferred to facilitate DOT and to avoid premature removal of drugs such as PZA and cycloserine. To avoid toxicity it is important to monitor serum drug concentrations in persons with renal failure who are taking cycloserine or EMB. There is little information concerning the effects of peritoneal dialysis on the clearance of antituberculosis drugs.

Liver Disease

INH, RIF, and PZA all can cause hepatitis that may result in additional liver damage in patients with preexisting liver disease. However, because of the effectiveness of these drugs (particularly INH and RIF), they should be used if at all possible, even in the presence of preexisting liver disease. If serum AST is more than three times normal before the initiation of treatment (and the abnormalities are not thought to be caused by tuberculosis), several treatment options exist. One option is to treat with RIF, EMB, and PZA for 6 months, avoiding INH. A second option is to treat with INH and RIF for 9 months, supplemented by EMB until INH and RIF susceptibility are demonstrated, thereby avoiding PZA. For patients with severe liver disease a regimen with only one hepatotoxic agent, generally RIF plus EMB, could be given for 12 months, preferably with another agent, such as a fluoroquinolone, for the first 2 months; however, there are no data to support this recommendation.

In all patients with preexisting liver disease, frequent clinical and laboratory monitoring should be performed to detect drug-induced hepatic injury.

Hepatitis and Anti-TB medications

WHO Recommendation for Anti-TB drug-induced hepatitis is:

  • If TB treatment has been stopped, Wait for liver function tests to normalize and resolution of the clinical symptoms (nausea, abdominal pain) before reintroducing the anti-TB drugs.
  • If the liver function tests are not available, it is advisable to wait for extra 2 weeks after resolution of jaundice and upper abdominal tenderness before restarting TB treatment.
  • If the signs and symptoms do not resolve and the liver disease is severe, the non-hepatotoxic regimen consisting of streptomycin, ethambutol and a fluoroquinolone should be started (or continued) for a total of 18-24 months.[14]
  • Reintroducing one drug at a time is the optimal approach, especially if the patient’s hepatitis was severe.
  • Once drug-induced hepatitis has resolved, the drugs are reintroduced one at a time. But if symptoms recur or liver function tests become abnormal again as the drugs are reintroduced, the last drug added should be stopped.
  • Some advise starting with rifampicin because it is less likely than isoniazid or pyrazinamide to cause hepatotoxicity and is the most effective agent .[14] [15] After 3–7 days, isoniazid may be reintroduced. In patients who have experienced jaundice but tolerate the reintroduction of rifampicin and isoniazid, it is advisable to avoid pyrazinamide.

Alternative regimens in Anti-TB induced Hepatitis

It depends on which drug is implicated as the cause of hepatitis.

  • If rifampicin is implicated, a suggested regimen without rifampicin is 2 months of Isoniazid, Ethambutol and Streptomycinfollowed by 10 months of Isoniazid and Ethambutol.
  • If Isoniazid cannot be used, 6-9 months of Rifampicin, Pyrazinamide and Ethambutol can be considered.
  • If Pyrazinamide is discontinued before the patient has completed the intensive phase, the total duration of isoniazid and rifampicin therapy may be extended to 9 months.[14]
  • If neither isoniazid nor rifampicin can be used, the non-hepatotoxic regimen consisting of Streptomycin, ethambutol and afluoroquinolone should be continued for a total of 18-24 months.
  • Hepatitis during the intensive phase of TB treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol: once hepatitis has resolved, restart the same drugs EXCEPT replace pyrazinamide with streptomycin to complete the 2-month course of initial therapy, followed by Rifampicin and Isoniazid for the 6-month continuation phase.
  • Hepatitis during the continuation phase: once hepatitis has resolved, restart Isoniazid and Rifampicin to complete the 4-month continuationphase of therapy.

Referencies

  1. 1.0 1.1 Harries AD, Zachariah R, Lawn SD (2009). "Providing HIV care for co-infected tuberculosis patients: a perspective from sub-Saharan Africa". Int J Tuberc Lung Dis. 13 (1): 6–16. PMID 19105873.
  2. Khan FA, Minion J, Pai M, Royce S, Burman W, Harries AD; et al. (2010). "Treatment of active tuberculosis in HIV-coinfected patients: a systematic review and meta-analysis". Clin Infect Dis. 50 (9): 1288–99. doi:10.1086/651686. PMID 20353364.
  3. 3.0 3.1 "2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition)".
  4. "Treatment of tuberculosis".
  5. "Co-trimoxazole prophylaxis".
  6. "Oxford journal TB lymphadenitis".
  7. "tech ortho TB" (PDF).
  8. Prasad K, Singh MB (2008). "Corticosteroids for managing tuberculous meningitis". Cochrane Database Syst Rev (1): CD002244. doi:10.1002/14651858.CD002244.pub3. PMID 18254003.
  9. Misra UK, Kalita J, Nair PP (2010). "Role of aspirin in tuberculous meningitis: a randomized open-label placebo-controlled trial". J Neurol Sci. 293 (1–2): 12–7. doi:10.1016/j.jns.2010.03.025. PMID 20421121.
  10. Sharma SK, Mohan A, Sharma A (2012). "Challenges in the diagnosis & treatment of miliary tuberculosis". Indian J Med Res. 135 (5): 703–30. PMC 3401706. PMID 22771605.
  11. Sanai FM, Bzeizi KI (2005). "Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment". Aliment Pharmacol Ther. 22 (8): 685–700. doi:10.1111/j.1365-2036.2005.02645.x. PMID 16197489.
  12. Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbaro JA (1990). "A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed, and cost-effective regimen". Ann Intern Med. 112 (6): 407–15. PMID pmid2106816 Check |pmid= value (help).
  13. American Thoracic Society. CDC. Infectious Diseases Society of America (2003). "Treatment of tuberculosis". MMWR Recomm Rep. 52 (RR-11): 1–77. PMID pmid12836625 Check |pmid= value (help).
  14. 14.0 14.1 14.2 "Treatment of tuberculosis". MMWR Recomm Rep. 52 (RR-11): 1–77. 2003. PMID 12836625. Unknown parameter |month= ignored (help)
  15. Saukkonen, JJ.; Cohn, DL.; Jasmer, RM.; Schenker, S.; Jereb, JA.; Nolan, CM.; Peloquin, CA.; Gordin, FM.; Nunes, D. (2006). "An official ATS statement: hepatotoxicity of antituberculosis therapy". Am J Respir Crit Care Med. 174 (8): 935–52. doi:10.1164/rccm.200510-1666ST. PMID 17021358. Unknown parameter |month= ignored (help)

Template:WH Template:WS