Tuberculosis Treatment Complete DRUGS – ATT (ANTITUBERCULAR TREATMENT)with MDR

Tuberculosis  Complete DRUGS -

• ATT (ANTITUBERCULAR TREATMENTHow to Prevent Hospital Acquired Infections Prevention and Causes. Read more ... »)  TREATMENT with Resistant and MDR Tubercular Treatment In All Cases

Complete RUGS – ATT (ANTITUBERCULAR TREATMENTEXTRA PULMONARY TUBERCULOSIS Diagnosis Signs and Symptoms with Treatment. Read more ... »)  TREATMENT

Case definitions:

• 1. Tuberculosis suspect : Any person with symp­toms or signsHow to Prevent Hospital Acquired Infections Prevention and Causes. Read more ... » suggestive of tuberculosis like coughInfluenza SARS and Whooping Cough Signs and Symptoms with Diagnosis and Treatment. Read more ... » more than 2 weeks.
• 2. Case of tuberculosis: A patient in whom tuber­culosis is confirmed bacteriologically
• 3. Definite case of tuberculosis : A patient with positive culture for M. tuberculosis complex or patient with 2 sputum smears showing AFB

Complete RUGS – ATT (ANTITUBERCULAR TREATMENT)  TREATMENT

History of treatment – Definitions for diagnosis:

• 1. New -A patient who has never taken antituber­cular treatment or taken for less than a month.
• 2. Relapse -A patient treated for TB and declared cured, or full treatment taken but smear or cul­ture for tuberculosis is positive.
• 3. Treatment after failure – A patient given An again, after failed previous treatment
• 4. Treatment after default – If a patient, bacterio­logically positive, interrupts treatment for 2 moths or more and starts An again.
• 5. Transfer in – A patient transferred from another TB centre for continuation of treatment.
• 6. Other – Any other case like chronicChronic Hepatitis Classification viral hepatitis Clinical features and Treatment. Read more ... » case, spu­tum positive at the end of repeat treatment.
• Sometimes pulmonary and extra pulmonary relapse cases may be smear-negative.

Complete RUGS – ATT (ANTITUBERCULAR TREATMENT)  TREATMENT

RUGS – ATT (ANTITUBERCULAR TREATMENT) There are 3 main properties of antituberculous drugs:

• 1. Bactericidal action
• 2 Sterilizing activity
• 3-To prevent resistance.

The first line agents consist of Isoniazid, Rifampin, Pyrazinamide, Ethambutol.

• These drugs are given orally, once a day.
• Peak level is at 4 hours and effect lasts for 24 hours. Second line drugs have lower efficacy and more toxicity. These are streptomycin, kanamycin, amikacin, capreomycin, ethionamide, cycloserine, and PAS(Paraamino salicylic acid).
• Other drugs are Ofloxacin, Levofloxacin, Gatifloxacin, Moxifloxacin, Clofazimine, thiacetazone, amoxycillin and linezolid.
• Isoniazid and Rifampicin are strong bactericidal drugs. Pyrazinamide and streptomycin are also bactericidal Streptomycin is bactericidal against rapidly multiply­ing tubercle bacilli.
• Rifampicin is the most potent sterilizing drug. Ethambutol and thiocetazone prevent resistance to drugs.

Standard Treatment Regimens: Treatment is started with:

• 1 st–  intensive phase for 2 months and
• 2 nd– continuation phase for 4 – 6 months.

Intensive phase consists of Isoniazid, Rifampicin, Pyrazinamide, and EthambutoL.

This intensive phase results in rapid killing of tubercle bacilli.

• In two weeks the infectious patient becomes non­infectious, symptomsHow to Prevent Hospital Acquired Infections Prevention and Causes. Read more ... » subside.
• If patient is smear positive he becomes smear nega­tive in two months.

Continuation phase consists of lesser drugs for longer time.

• This makes the patient diseaseHow to Prevent Hospital Acquired Infections Prevention and Causes. Read more ... »-free and prevents re­sistance and relapse.
• Patients with large bacillary load (which means smear­positive or HIV-infected patients),’ are given short course chemotherapy with four drugs during initial phase and two drugs during continuation.
• Patients negative for HIV and smear negative tuber­culosis are given rifampicin, isonex, pyrazinamide and ethambutol.
• Ethambutol may not be given in young children and primary tuberculosisTuberculosis caused by Mycobacterium tuberculo­sis about diagnosis classification. Read more ... ».

Retreatment Regimen:

• For patients with smear or culture positive tuberculo­sis, 5 drugs in initial phase and 3 drugs in continua­tion phase should be given.
• Rifampicin, Isonex, Ethambutol are given throughout the treatment.

Standard code for Anti- TB regimens  :

• Each antitubercular drug has an abbreviation as fol­lows:
• Rifampicin – R
• Isoniazid – H
• Pyrazinamide – Z
• Streptomycin – S
• Ethambutol – E
• Thioacetazone – T.

Any regimen consists of :

1. Initial phase
2. Continuation phase

• The number before a phase is duration of that phase in months.
• Letters in brackets indicate the names of drugs.
• A subscript after the letters in brackets indicates num­ber of doses per week. Eg. 2 (HRZE) / 4 (HR)3
• This means that initial phase of 2 months consists of Isoniazid, Rifampicin, Pyrazinamide, Ethambutol. The

TB Diagnostic TB Patients Category

• New smear positive patients; New smear negative PTB with extensive parenchymal involvement;
• Severe concomitant HIV disease or severe forms of EPTB
• Previously treated sputum smear-positive PTB :
• - relapse;

treatment after interruption; treatment failure

• New smear negative PTB (other than in Category I); Less severe forms of EPTB
• Chronic and MDR – TB cases (still sputum positive after supervised re-treatment)

Treatment Regimen in Special Conditions  Pregnancy:

 

• Streptomycin is unsafe. It is hepatotoxic to fetus and so should not be used in pregnancy.

Breastfeeding :

• All drugs are safe. Baby can be given Isoniazid during infectious stage of mother and for 3 months after that.

OralHow Can Protect Your Oral Health. Read more ... » contraception:

• Rifampicin interacts with oral contraceptives and de­creases their efficacy.

Liver disease:

• Isoniazid, Rifampicin and Pyrazinamide can cause hepatitis.
• Rifampicin is least toxic, but can cause cholestatic jaundiceCauses of jaundice with diagnosis and bio markers. Read more ... ».
• Pyrazinamide is most hepatotoxic.
• Patients with chronic liver disease should not take Pyrazinamide.
• In chronic liver disease patient can take isoniazid and rifampicin with streptomycin and etham­butol for 8 months.
• In acuteHow to Prevent Hospital Acquired Infections Prevention and Causes. Read more ... » he(?atitis, treatment should be delayed till hepatitis resolves otherwise streptomycin and etham-
• continuation phase is of 4 months consisting of Iso­niazid and Rifampicin given 3 times / week.

TB treatment regimens

1. Initial phase (Daily Continuation phase
2. or 3 times weekly) (Daily or 3 times weekly)a

• Specially designed standardized or individualized regimens are suggested for this category
• ethambutol can be given for 3 months and when hepatitis is resolved, isoniazid and rifampicin may be given.
• If acute hepatitis does not resolve for many months then only Streptomycin and Ethambutol should be continued for 12 months.

RenalDiabetic Nephropathy and Renal complications of DM (Diabetes Mellitus). Read more ... » Failure:

• In renal failure, Isoniazid, Rifampicin and Pyrazina­mide can be given in normal doses.
• Pyridoxin should be given with Isoniazid to prevent peripheral neuropathy if renal failure patients.
• Streptomycin and Ethambutol are avoided or given in low doses.
• Thiocetazone should not be used.
• Patients with renal failure should be on 2 HRZ / 4 HR.

HIV infected patients:

• Thiocetazone is not given. Rest of the drugs can be given.

Chronic and MDR (Mutli-Drug Resistant) TB :

• Chronic tuberculosis is a patient with tuberculosis who. is sputum-positive after standard treatment with es­sential drugs given for complete duration.
• MDR TB is a patient who is Multi-Drug Resistant, i.e. who has active tuberculosis with bacilli resistant to at least Rifampicin and Isoniazid.

Minor

• Anorexia, nauseaNausea and Vomiting. Read more ... », abdominal pain Joint pains.
• Burning sensation in the feet
• Orange j red urine
• Pyrazinamide Isoniazid

Major

• Itching, skin rash Deafness (no wax on auroscopy) DizzinessDizziness cause diagnosis treatment. Read more ... » (vertigo and nystagmus) Jaundice (other causesHow to Prevent Hospital Acquired Infections Prevention and Causes. Read more ... » excluded) hepatitis
• Confusion (suspect drug induced acute liver failure if jaundice present)
• Visual impairment (other causes excluded)
• ShockShock Presentation Risk Factors Pathogenesis Management Treatment. Read more ... », purpura, acute renal failure
• Thioacetazone (SHRZ) Streptomycin
• Isoniazid, Pyrazinamide, rifampicin
• Reserved drugs for tuberculosis are Amikacin, Kapriomycin, Ciprofloxacin, Cycloserine, Ethionamide, Kanamycin, Ofloxacin, p-aminosalycilic acid.

Management

• Continue anti-TB drugs, check drug doses Give drugs with small meals or last thing at night
• Aspirin
• Pyridoxine 100 mg daily
• Reassurance, Patients should be told when starting treatment that this commonly happens and is normal.

Stop responsible drug(s) Stop anti-TB drugs

• Stop streptomycin use ethambutol
• Stop anti-TB drugs
• Urgent liver function tests and prothrombin time

ManagementChronic Renal Failure (CRF) Risk factors Causes Stage CRF Treatment. Read more ... » of Drug Induced HepatitisToxic Hepatitis and Drug Induced Hepatitis Diagnosis and Treatment. Read more ... »:

• Isoniazid, Pyrazinamide, Rifampicin, and rarely Etham­butol can damage the liver.
• When a patient develops hepatitis during tubercular treatment, all An should be stopped till liver func­tion tests become normal, or An is not given for 2 weeks after jaundice has disappeared. Rifampicin can give rise to jaundice without hepatitis and symptoms.
• For patients with drug-induced hepatitis Streptomy­cin, and Ethambutol may be given.

Anti Tuburculous Drug Isoniazid

• • Highly bactericidal
• · Given orally (1M also available)
• · Dose 5 mgjkg or 300 mgjday
• · Preventive dose 300 mgjday for 6 months
• · Contraindications – Active liver disease,

Hypersensitivity.

• In malnutrition, alcoholics, and diabetics, patient should be given pyridoxine 10 mgjday with Isoniazid.

Adverse Effects :

• Peripheral neu ropathy Optic neuritis
• Toxic psychosis Generalized convulsions Hepatitis.

Side effects :

• Nausea
• VomitingNausea and Vomiting. Read more ... » Dizziness
• Blurred vision Slurring of speech Seizures.

Rifampicin –

• Strong bactericidal drug
• Should be given 30 minutes before meals Dose is 10 m k or 150 – 600 mg daily
• The drug causes red coloration of urine, tears, saliva, sweat, sputum and contact lenses. Contraindications:
• Hypersensitivity Liver dysfunction.

Adverse effects :

• Gastro-intestinal disturbances FeverHow to Manage Hay Fever at Home. Read more ... »
• Flu-like syndromeMetabolic,Insulin Resistance Syndrome X Causes Symptoms. Read more ... » Thrombocytopenia Skin rashes Exfoliative dermatitis Oliguria
• Dyspnoea
• Hemolytic anaemiaHemolytic Anaemia Classification Diagnosis And Treatment. Read more ... »
• Hepatitis (which may be fatal).

Pyrazinamide

• Weak bactericidal, potent sterilizing activity. Dose – 30 mgLkgLQay.

Contraindications :

• Hypersensitivity Hepatic impairment.

Adverse effects :

• Gastrointestinal disturbances Increased serum transaminases Hyperuricemia
• GoutDisease of Joints and Musculoskeletal Disorders OSTEOARTHRITIS and GOUT. Read more ... »
• Arthralgia.

Streptomycin It is bactericidal.

• Given by deep intramuscular injection.
• Dose – 15 mg/kg/day or 750 mg – 1 gm /day. Contraindications :
• Hypersensitivity Auditory nerve deafness Myasthenia gravis
• Should not be used in pregnancy as it causes deafness and nephrotoxicity in the fetus.

 

Adverse effects :

 

• Injection abscess Hypersensitivity
• Impairment of vestibular function – HeadacheHeadache. Read more ... », vomiting, vertigo and tinnitus
• Nephrotoxicity
• Hemolytic anaemia
• Aplastic anaemiaAplastic Anaemia Causes Symptomes Diagnosis And Treatment. Read more ... »
• Agranulocytosis
• Thrombocytopenia
• Streptomycin should not be given to patients who are to receive neuromuscular blocking agents during anaesthesia.

 

Ethambutol –

• Its role is to prevent emergence of resistant strains. Dose – 15 mgLl<g/daL

Contraindication:

 

• . Hypersensitivity
• .• Optic neuritis
• Creatinine clearance < 50 ml/min.

 

Adverse effects :

 

• Optic neuritis – Visual impairment and loss of colour vision
• BlindnessOphthalmologic Complications of DM (Diabetes Mellitus). Read more ... »
• Peripheral neuritis