Module 4 Basic Principles of Treatment

“ubo! ubo! ubo!” (cough for 2 weeks or more) Did not take medication medication In Loving Memory of In Loving Memory of DEAD Not taking medication Cough worsens Did not take medication medication Active TB Patient

“ubo! ubo! ubo!” (cough for 2 weeks or more) Not regularly taking medication 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 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 DRUGS Rifampicin – bactericidal, extra/intra-cellular Isoniazid – bactericidal, extra-cellular FIRST LINE SUPPLEMENTAL DRUGS Pyrazinamide – 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