Patient Initial Evaluation & Follow up

Pretreatment screening and evaluation: Initial evaluation serves to establish a baseline and may identify patients who are at increased risk for adverse effects or poor outcomes.

During treatment evaluation: patients should be monitored closely for signs of improvement, side effects or signs of treatment failure. The recurrence of TB symptoms after sputum conversion, for example, may be the first sign of treatment failure. For children, normal growth rate should be resumed after a few months of successful treatment.

The most important objective evidence of improvement is conversion of the sputum smear and culture to negative. chest radiograph may be unchanged or show only slight improvement, especially in re-treatment patients with chronic pulmonary lesions.

initial pretreatment clinical investigation includes: 1.A thorough medical history and physical examination. 2. Direct smear examination 3.DST for first and second line anti-TB drugs. 4. Liver functions: Total serum Bilirubin SGPT & SGOT Total serum albumin, total serum protein and A/G ratio.

5.Serum Creatinine, blood urea, complete urine analysis with estimation of total urine protein content 6.Serum uric acid. 7.Fasting and PP blood sugar. 8.Serum Sodium and Potassium. 9.HIV 10.Pregnancy test. 11.Initial chest x-ray

Monitoring during DR-TB treatment

Sputum smear and culture Monthly until conversion then monthly smear and culture quarterly Drug Susceptibility Test DRS Initially then for patient who remains culture positive Weight Initially then monthly. Chest radiograph Initially then every 6 months Serum creatinine Initially then monthly while receiving injectable drugs. Serum potassium Monthly while receiving injectable drugs.

TSH Every 6 months if receiving ethionamide/prothionamide or PAS and monitor monthly for signs and symptoms of hypothyroidism. Liver enzymes Periodic monitoring (every 1–3 months) in patients receiving Pyrazinamide for extended periods or for patients at risk for or with symptoms of hepatitis HIV Initially and repeat if clinically indicated. Pregnancy test Initially and repeat if indicated.

Monitoring of side effects should also include base line and check of: 1.Full blood count. 2.In highly risk patients (over 50 years, renal insufficiency, DM, HIV, underweight), creatinine should be evaluated every week or every other week for at least the first month of treatment.

3.Creatinine clearance may be needed for high risk group patients. 4.Audiometry or hearing evaluation. 5.Visual acuity and color vision evaluation. 6.If Serum potassium is low, check the Magnesium and Calcium levels

Special attention should be paid for: Liver toxicity Vestibular and hearing toxicity with injectable drugs Psychiatric disorders with Cycloserine Allergic reactions Hematological changes.

Summary of important adverse reactions SystemCommon, mild adverse reaction Moderate to severe adverse reactions NeurologicalDizziness Headaches Fatigue Somnolence Insomnia Seizure Peripheral neuropathy Otoxocity Optic neuritis PsychiatricDepression Irritability Anxiety Mood/behavior changes Psychosis Suicidal ideation DermatologicChanges in skin color Photosensitivity Dry skin Anaphylaxis Stevens-Johnson Syndrome

Summary of important adverse reactions, (cont.) System Common, mild adverse reaction Moderate to severe adverse reactions EndocrineWorsened hyperglycemia Menstrual cycle changes Hypothyroidism GastrointestinalNausea Emesis Diarrhea Abdominal bloating Abdominal cramping Gastritis Fat malabsorbtion Lactose intolerance Gastric ulcers Hepatitis Renal and electrolyteRenal insufficiency Hypokalemia Hypomagnesemia OtherArthralgias Myalgias Muscular cramps Vaginal candidiasis Dehydration Initial weight loss

Side effects, general considerations All anti-tuberculosis drugs are associated with side effects. Adverse effects are not a contraindication to appropriate treatment. Poorly managed side effects may lead to non-adherence or inappropriate therapy. Minor side effects are common during initial months of treatment. Serious reactions are rare but require attention.

Side effects, general considerations, (cont.) Community health workers and DOT enable close surveillance for adverse effects during ambulatory treatment besides, close communication with patient and family members. Timely diagnosis and early management are crucial. Changes to MDR-TB regimen are rarely indicated Ambulatory management is usually adequate.

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