Tuberculosis medical therapy special conditions: Difference between revisions

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===Co-trimoxazole===
===Co-trimoxazole===
Preventive therapy with co-trimoxazole should be initiated as early as possible in all TB patients who are HIV-positive.  Co-trimoxazole should be continued during the entire TB treatment.
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.<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>




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The exact mode of activity is not clear but co- trimoxazole is known to prevent Pneumocystis jirovecii and malaria and is likely to have an impact on a range of bacterial infections in HIV-positive TB patients.


A system for providing co-trimoxazole preventive therapy to all people living with HIV who have active TB should be established by TB and HIV programmes. Con- tinuation after TB treatment is completed should be considered in accordance with national guidelines.


For co-trimoxazole dosages, contraindications, and side-effects and their manage- ment, see reference 20.


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{{details|HIV coinfection with tuberculosis}}
{{details|HIV coinfection with tuberculosis}}
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===Tuberculous Pericarditis===
===Tuberculous Pericarditis===
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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}}
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===Renal Tuberculosis===
===Renal Tuberculosis===
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‡ In this group decisions to prolong the continuation phase should be made on an individual basis.
‡ 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:
====Renal Insufficiency and End-Stage Renal Disease====
*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)
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.
*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====
==Liver Disease==
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[[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.  


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==Liver Disease==
==Referencies==
==Referencies==
{{reflist|2}}
{{reflist|2}}

Revision as of 20:36, 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]

Overview

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]

1. 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.

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

3. 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]

4. HIV-positive patients with TB should receive TB treatment, as least for the same period of time as HIV-negative patients.

Patients Taking ART

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.[1][5]


Extrapulmonary

Tuberculous Lymphadenitis

Skeletal Tuberculosis

Tuberculous Meningitis

Miliary Tuberculosis

Tuberculosis Peritonitis

Tuberculous Pericarditis

Renal Tuberculosis

Liver Disease

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".

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