Module 4

Basic Principles of Treatment

“ubo! ubo! ubo!”(cough for 2 weeks or more)

Did not Did not taketake

medicatiomedicatio

nn

In Loving Memory ofIn Loving Memory of

DEADDEAD

Not taking medicationNot taking medication

Cough worsens

Did not Did not taketake

medicationmedication

Active TB Patient

“ubo! ubo! ubo!”(cough for 2 weeks or more)

Not regularly taking Not regularly taking medicationmedication

Takes medication

Medication is Discontinued or

irregular

Coughing recurs & Bacteria multiplies

Feels better but bacteria is still present in the lungs

Active TB Patient

Takes medication (2 mos.)

Takes medication (4-6 mos.)

Feels better but bacteria is still present in the lungs cured

Regularly taking medicationRegularly taking medication

“ubo! ubo! ubo!”(cough for 2 weeks or more)

Active TB Patient

Patients should be given the safest, most effective therapy in prescribed duration.

Multiple drugs to which the organisms are (likely) susceptible must be chosen.

Addition of a single drug to a failing regimen is not recommended.

Patient’s complete adherence to therapy must be ensured. – DOTS for all!

Basic Principles of Treatment

FIRST LINE ESSENTIAL DRUGSRifampicin – bactericidal, extra/intra-

cellular

Isoniazid – bactericidal, extra-cellular

FIRST LINE SUPPLEMENTAL DRUGSPyrazinamide – weakly bactericidal, w/in

macrophages, acute inflammation

Ethambutol – bacteriostatic/cidal at higher doses; extra/intra cellular

Streptomycin – bactericidal

Basic Principles of Treatment

• Interacts with oral contraceptive pills, seizure meds, warfarin, methadone / opiates

• Major side effects: Hepatitis (nausea, vomiting, abdominal pain, jaundice)– Contraindicated in GI distress and rash

– Bleeding problems, flu-like symptoms

– Risk increases with alcoholism, liver disease, and use of other hepatotoxic drugs

Rifampicin

• Major side effects: Hepatitis (nausea, vomiting, abdominal pain, jaundice)

• Risk increases with alcoholism, presence of liver disease, use of other medications– Other contraindications: GI distress and rash

– Occasional peripheral neuropathy preventable with Vitamin B6 supplementation

Isoniazid

• Major side effects: Hepatitis (nausea, vomiting, abdominal pain, jaundice)

• Risk increases with liver disease, alcoholism, other hepatotoxic drugs– Other common C/I include GI distress and rash

– Joint aches, and hyperuricemia

Pyrazinamide

• Major side effects: Optic Neuritis (blurred vision, altered color vision)

• Visual monitoring suggested while on treatment

Ethambutol

• Administered via intra-mascular (IM) route

• May be substituted by kanamycin, capreomycin, or amikacin.

• Major side effects: ear damage (balance problems, hearing loss, ringing in the ear); kidney damage

Streptomycin

ReassuranceRifampicinOrange-red urine

Pyridoxine 100mg/day

IsoniazidBurning sensation

Aspirin/ NSAIDSPyrazinamideJoint pains

Give drugs last thing at night

RifampicinAnorexia, nausea, abdominal pain

Minor

ManagementDrugs probably responsible

Side effects

Symptom-based Approach to Adverse Effects of TB Drugs

Stop RifampicinRifampicinShock, Purpura, ARF

Stop EEthambutolVisual impairment (other causes excluded)

Stop drugs, urgent liver function tests and PT

Most anti-TB drugs

Vomiting and Confusion (suspect drug-induced liver failure)

Stop drugs, re-introduce

Isoniazid, Rifampicin, PZA

Jaundice

Stop S, use EStreptomycinDizziness (vertigo and nystagmus)

Stop S, use EStreptomycinDeafness (no gross abnormality on otoscopy)

Major

Symptom-based Approach to Adverse Effects of TB Drugs