Pulmonology Book

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Active Tuberculosis TreatmentAka: Active Tb Treatment, Active Tuberculosis Special Circumstances, Drug-Induced Hepatitis from Antituberculous Drugs

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  1. Protocols
    1. Susceptible Tb Treatment
    2. Possibly Resistant Tb Treatment
    3. Multiple Drug Resistant Tb Treatment
  2. Precautions
    1. Tuberculosis requires long-term treatment (6-24 months)
    2. Regimens for Tuberculosis treatment must be multi-drug
      1. Four drugs should be used initially until culture
      2. Never add a single drug to a failing regimen
    3. Patients must be monitored at least monthly
    4. Patient noncompliance is a major problem
      1. Consider intermittent therapy
      2. Consider Directly observed therapy
  3. Drug Interactions
    1. Review drug interactions before use (esp. Rifampin)
  4. Adverse Effects
    1. Gastrointestinal upset
      1. Consider taking medication with food
    2. Hepatotoxicity (AST 3-5x normal)
      1. See Also Hepatotoxin
      2. Consider alternatives below if advanced liver disease
      3. Drugs most likely to cause Drug-Induced Hepatitis
        1. Isoniazid
        2. Rifampin
        3. Pyrazinamide
      4. Alternative drugs if Drug-Induced Hepatitis occurs
        1. Capreomycin
        2. Fluoroquinolone
        3. Ethambutol
        4. Streptomycin
        5. Amikacin
        6. Kanamycin
  5. Management: Special Circumstances
    1. Human Immunodeficiency Virus Infection
      1. Avoid once weekly continuation phase protocols
    2. Pediatric patients
      1. Start empiric treatment immediately if suspected
        1. High risk of Disseminated tuberculosis
      2. Initial Protocol
        1. Three drug regimen indicated in most cases
          1. Regimen: Isoniazid, Pyrazinamide, Rifampin
          2. Ethambutol avoided due to decreased vision risk
        2. Four drug regimen (inc. Ethambutol) indications
          1. Upper lobe infitrate
          2. Cavitation
          3. Productive cough
    3. Pregnant Women
      1. Initial Regimen: Isoniazid, Rifampin, Ethambutol
      2. Give Pyridoxine 25 mg daily (prevents Neuropathy)
      3. Do not use Streptomycin in pregnancy
      4. Pyrazinamide appears safe in pregnancy
        1. Less studied, and avoided in some regimens
        2. Give 7 month continuation phase if no Pyrazinamide
    4. Lactation
      1. May continue to breast feed on antituberculous drugs
      2. Give Pyridoxine 25 mg daily (prevents Neuropathy)
  6. Management: Non-compliance
    1. General
      1. Compliance management is imperative
      2. Non-compliance causes treatment failures, resistance
    2. Dosing should be observed unless compliance assured
    3. Consider fixed dose combinations
      1. Rifater
        1. Contents
          1. Rifampin 120 mg
          2. Isoniazid 50 mg
          3. Pyrazinamide 300mg
        2. Treat for first 2 months of daily therapy
          1. Weight <44 kg: 4 tabs qd
          2. Weight 45-54 kg: 5 tabs qd
          3. Weight >55 kg: 6 tabs qd
      2. Rifamate
        1. Rifampin 300 mg
        2. Isoniazid 150 mg
  7. References
    1. Frieden (2003) Lancet 362:887
    2. Potter (2005) Am Fam Physician 72:2225

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