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==Special Conditions== | ==Special Conditions== | ||
===HIV Coinfection=== | ===HIV Coinfection=== | ||
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Recommendations for the treatment of tuberculosis in [[HIV]]-infected adults: | |||
The recommended treatment of TB disease in HIV-infected adults (when the disease is caused by organisms that are known or presumed to be susceptible to first-line drugs) is a 6-month regimen consisting of: | |||
*For the first 2 months: An initial phase of [[isoniazid]] (INH), a [[rifamycin]], [[pyrazinamide]] (PZA), and [[ethambutol]] (EMB). | |||
*For the last 4 months: A continuation phase of INH and a rifamycin. | |||
*Patients with advanced HIV (CD4 counts < 100/µl) should be treated with daily or three-times-weekly therapy in both the initial and the continuation phases. | |||
*Twice weekly therapy may be considered in patients with less-advanced immunosuppression (CD4 counts ≥ 100/µl). | |||
*Once-weekly INH/rifapentine in the continuation phase should not be used in any HIV-infected patient. | |||
Recommendations for the treatment of tuberculosis in [[HIV]]-infected adults are, with a few exceptions, the same as those for HIV-uninfected adults. The [[INH]]--[[rifapentine]] once weekly continuation phase is contraindicated in HIV-infected patients because of an unacceptably high rate of relapse, frequently with organisms that have acquired resistance to [[rifamycin]]s. The development of acquired [[rifampin]] [[drug resistance|resistance]] has also been noted among HIV-infected patients with advanced [[immunosuppression]] treated with twice weekly rifampin- or [[rifabutin]]-based regimens. Consequently, patients with [[CD4]]+ cell counts <100/µl should receive daily or three times weekly treatment. DOT and other adherence-promoting strategies are especially important for patients with HIV-related tuberculosis. | |||
Management of HIV-related tuberculosis is complex and requires expertise in the management of both HIV disease and tuberculosis. Because HIV-infected patients are often taking numerous medications, some of which interact with antituberculosis medications, it is strongly encouraged that experts in the treatment of HIV-related tuberculosis be consulted. A particular concern is the interaction of [[rifamycin]]s with [[antiretroviral agent]]s and other antiinfective drugs. [[Rifampin]] can be used for the treatment of tuberculosis with certain combinations of antiretroviral agents. [[Rifabutin]], which has fewer problematic drug interactions, may also be used in place of rifampin and appears to be equally effective although the doses of rifabutin and antiretroviral agents may require adjustment. As new antiretroviral agents and more pharmacokinetic data become available, these recommendations are likely to be modified. | |||
On occasion, patients with HIV-related tuberculosis may experience a temporary exacerbation of symptoms, signs, or radiographic manifestations of tuberculosis while receiving antituberculosis treatment. This clinical or radiographic worsening (paradoxical reaction) occurs in HIV-infected patients with active tuberculosis and is thought to be the result of immune reconstitution as a consequence of effective [[antiretroviral therapy]]. Symptoms and signs may include high [[fever]]s, [[lymphadenopathy]], expanding [[central nervous system]] lesions, and worsening of [[chest radiographic]] findings. The diagnosis of a paradoxical reaction should be made only after a thorough evaluation has excluded other [[etiologies]], particularly tuberculosis treatment failure. [[Nonsteroidal antiinflammatory agent]]s may be useful for symptomatic relief. For severe paradoxical reactions, [[prednisone]] (1--2 mg/kg per day for 1--2 weeks, then in gradually decreasing doses) may be used, although there are no data from controlled trials to support this approach. | |||
{{details|HIV coinfection with tuberculosis}} | |||
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===Extrapulmonary=== | ===Extrapulmonary=== | ||
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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 [[corticosteroid]]s is recommended for patients with tuberculous pericarditis and tuberculous meningitis. | |||
:*In tuberculous meningitis, ethambutol should be replaced by streptomycin. | |||
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! style="padding: 0 5px; font-size: 100%; background: #A5B2D6" align=center | ''{{fontcolor|#000000|Statandard Regimens For New TB Patients With Drug-Susceptible TB}}'' | |||
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! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=left | ''{{fontcolor|#6C7B8B|Intensive Initial Phase}}'' | |||
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| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" | ▸ '''''Initial Phase''''': 2 months of '''HRZS''' <sup>†</sup> | |||
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! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=left | ''{{fontcolor|#6C7B8B|Continuation phase}}'' | |||
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| rowspan="1" style="font-size: 95%; padding: 0 5px; background: #DCDCDC" | ▸ '''''Continuation Phase''''': 6-9 months <sup>‡</sup> of '''HR''' | |||
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‡ In this group decisions to prolong the continuation phase should be made on an individual basis. | |||
====Tuberculous Pericarditis==== | |||
With the use of antituberculosis chemotherapy, survival rate in tuberculous pericarditis has improved dramatically. Mortality rate in preantibiotic era was 80-90%<ref>Harvey AM, Whitehill MR. Tuberculous pericarditis. Medicine. 1937; 16: 45–94</ref>. At present it is 8-17%<ref name="pmid472922">{{cite journal| author=Desai HN| title=Tuberculous pericarditis. A review of 100 cases. | journal=S Afr Med J | year= 1979 | volume= 55 | issue= 22 | pages= 877-80 | pmid=472922 | doi= | pmc= | url= }} </ref><ref name="pmid7185934">{{cite journal| author=Bhan GL| title=Tuberculous pericarditis. | journal=J Infect | year= 1980 | volume= 2 | issue= 4 | pages= 360-4 | pmid=7185934 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7185934 }} </ref> and 17-34% if associated with [[HIV]]<ref name="pmid10908256">{{cite journal| author=Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A| title=Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. | journal=Heart | year= 2000 | volume= 84 | issue= 2 | pages= 183-8 | pmid=10908256 | doi= | pmc=PMC1760932 | url= }} </ref>. 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="pmid2106816">{{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=2106816 | doi= | pmc= | url= }} </ref>. Short course chemotherapy is beneficial in [[HIV]] infected patients<ref name="pmid7862181">{{cite journal| author=Perriëns JH, St Louis ME, Mukadi YB, Brown C, Prignot J, Pouthier F et al.| title=Pulmonary tuberculosis in HIV-infected patients in Zaire. A controlled trial of treatment for either 6 or 12 months. | journal=N Engl J Med | year= 1995 | volume= 332 | issue= 12 | pages= 779-84 | pmid=7862181 | doi=10.1056/NEJM199503233321204 | pmc= | url= }} </ref>. | |||
American Thoracic Society, CDC, and Infectious Diseases Society of America recommends use of [[corticosteroids]] ([[prednisone]]) as adjunctive therapy for tuberculous pericarditis during the first 11 weeks of [[TB#treatment|antituberculosis therapy]]<ref name="pmid12836625">{{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=12836625 | doi= | pmc= | url= }} </ref>. Following are the dosage recommendations: | |||
*Adults: Prednisone 60 mg/day (or the equivalent dose of prednisolone) 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. | |||
{{details|Tuberculous pericarditis}} | |||
====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. | |||
====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. | |||
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===Liver Disease=== | ===Liver Disease=== | ||
Revision as of 14:38, 17 September 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]