Tuberculosis Treatment

The treatment of TB is centered on curing the individual patient and decreasing the
transmission of TB bacteria to other people.

The objectives of TB therapy are:

Cure the individual patient and minimize risk of death and disability;
Reduce transmission of M. tuberculosis to other persons; and
Prevent the development of drug resistance during therapy

Tuberculosis treatment includes two stages of the early stages and the advanced stage :

Early stage: treatment is given daily, this stage aims to effectively reduce the amount
of germs present in the patient's body. Initial treatment of each new patient should be
done for 2 months. In general with regular treatment and without complications, the
transmission rate has decreased after 2 weeks of treatment.
Advanced treatment: this stage treatment is intended to kill the remaining germs that
remain in the patient's body especially the presisten bacteria so that the patient can
recover completely without recurrence.

Drugs used:

1. The main drug types (line 1) used are:

Rifampicin
INH
Pyrazinamide
Streptomycin
Ethambutol

2. Combination of fixed dose (Fixed dose combination). This fixed-dose combination

consists of:

Four antituberculosis drugs in one tablet, ie Rifampicin 150 mg, isoniazid 75 mg,
pyrazinamide 400 Mg and ethambutol 275 mg and
Three antituberculosis drugs in one tablet, ie Rifampicin 150 mg, isoniazid 75 mg
and pyrazinamide.400 mg

3. Other types of additional drugs (line 2)

Kanamycin
Quinolones
Other drugs are still under investigation; Macrolides, Amoxicillin + clavulanic acid
Rifampicin and INH derivatives
Treatment of tuberculosis is divided into:

Pulmonary TB (new case), smear positive or extensive lesions Paired alloy: 2 RHZE /
4 RH alternate: 2 RHZE / 4R3H3 or (P2TB program) 2 RHZE / 6HE this alloy is
recommended for :
a. Pulmonary tuberculosis (+), new cases
b. Pulmonary tuberculosis (-), with radiological features of extensive lesions
(Including lung)\
c. Tuberculosis in extrapulmonary case

Advanced phase treatment, if necessary can be given For 7 months, with 2RHZE / 7
RH alloys, and Alternative 2RHZE / 7R3H3, as in:

a. TB with extensive lesions

b. Combined with comorbid disease (Diabetes Mellitus, Use of
immunosuppressive drugs / corticosteroids)
c. TB severe cases (miliens, etc.)

If there is a culture facility and resistance test, treatment adjusted for resistance test
results

Pulmonary TB (new case), smear negative

Paired alloy: 2 RHZ / 4 RH alternative: 2 RHZ / 4R3H3 or 6 RHE These alloys are
recommended for:
a. Smear-negative pulmonary tuberculosis with radiological features of the lesion
minimal
b. Tuberculosis outside the lung mild cases
Pulmonary TB cases relapse
In pulmonary tuberculosis cases minimal use of 4 Range of OAT in intensive phase
for 3 months (if any resistance test results can be given the appropriate drug test
results resistance). Prolonged treatment phase of 6 months or Longer than previous
treatment, so the alloy. Given drug: 3 RHZE / 6 RH If there is no / no resistance test
done, then alternatively given the drug alloy: 2 RHZES / 1 RHZE / 5 R3H3E3 (P2TB
Program)
Pulmonary TB treatment failure cases
Treatment should be based on resistance test results, with a minimum use 4 -5 OAT
with a minimum of 2 OAT that is still sensitive (if H is resistant, fixed Given). With a
minimum duration of treatment for 1 2 Year. Waiting for resistance test results can
be given first 2 RHZES, to then proceed according to the resistance test
- If there is no / no resistance test done, then Alternatively given the drug alloy:
2 RHZES / 1 RHZE / 5 H3R3E3 (P2TB Program)
- Can also be considered surgery for Get optimal results
- Preferably the case of failed treatment is referred to the lung expert
Lung TB case negligent treatment
 Patients with lung TB cases negligent treatment, will begin treatment again according
to the following criteria:
a. Patients who stop treatment <2 Week, OAT treatment resumes according to
schedule, Patients stop treatment 2 weeks
i. Treatment 4 months, negative smear and clinic, Radiologic negative,
treatment of OAT STOP
ii. Treatment> 4 months, BTA positive: treatment starting from scratch
with more medicinal alloy stronger and longer treatment period
iii. Medicated <4 months, smear positive: treatment starting from scratch
with the same drug alloy
iv. Medicated <4 months, stop treatment> 1 month, BTA is negative, but
clinical and / or radiologic Positive: treatment starts from baseline
with the same drug alloy
v. Medicated <4 months, smear negative, stop treatment 2-4 weeks of
treatment are resumed accordinglySchedule.
Chronic pulmonary TB cases
i. Chronic pulmonary tuberculosis treatment, if no results test resistance, give
RHZES. If there is already a test result resistance, adjust to the resistance test
results (At least there are 2 kinds of OAT that is still sensitive with H still
given despite resistance) plus with other drugs such as quinolones, betalactam,
Macrolides
ii. If not able to be given INH for life
iii. Consider surgery to improve possible healing
iv. Chronic pulmonary TB cases need to be referred to the lung specialist

Dose of OAT

Rifampicin.
10 mg / kg body weight, maximum 600mg 2-3X / week or
BB> 60 kg: 600 mg
BB 40-60 kg: 450 mg
BB <40 kg: 300 mg
Intermittent dose of 600 mg / times
INH
5 mg / kg BW, maximum 300mg, 10 mg / kg BW 3 times a week, 15 mg / kg BB 2
times a week or 300 mg / day
For adults. Interferes: 600 mg / times
Pyrazinamide
Intensive phase 25 mg / kg BW, 35 mg / kg BW 3 times a week, 50 mg / kg BB 2
times a week or:
BB> 60 kg: 1500 mg
BB 40-60 kg: 1 000 mg
BB <40 kg: 750 mg
Etambutol
 intensive phase 20mg / kg BW, 15mg advanced phase/ Kg BW, 30mg / kg BW 3
times a week, 45 mg / kg BB 2 times a week or:
BB> 60kg: 1500 mg
BB 40 -60 kg: 1000 mg
BB <40 kg: 750 mg
Intermittent dose 40 mg / kgBB / times
Streptomycin
15mg / kgBB or BB> 60kg: 1000mg
BB 40 - 60 kg: 750 mg
BB <40 kg: according to BB
Fixed-dose combinations
WHO 1999 recommendations for fixed dose combinations, Patients only take 3-4
tablets a day during the phase Intensive, while the advanced phase can use
Combination dose of 2 antituberculosis drugs as long as This has been used in
accordance with the treatment guidelines. In the case of a fixed dose combination
drug, When experiencing serious side effects should be referred To the hospital /
facility that can handle it.

Side Effects of OAT:

Most TB patients can resolve treatment without side effects. But a small part can
experiencing side effects, therefore monitoring The possibility of side effects is very
important during treatment. Side effects that occur can be mild or severe, if effects side light
and can be treated with symptomatic drugs then OAT administration can be continued.

a. Isoniazid (INH)
Mild side effects can be signs of poisoning on the peripheral nerve, tingling, burning
in the legs and pain muscle. This effect can be reduced by giving pyridoxine At a dose
of 100 mg daily or with vitamin B complex. In such circumstances treatment can
Forwarded. Another disorder is deficiency Pyridoxine (pellagra syndrome) Severe
side effects can be hepatitis that can arise In approximately 0.5% of patients. In case
of hepatitis Drug or jaundice, discontinue OAT and treatment According to TB
guidelines in special circumstances
b. Rifampicin
Mild side effects that can occur and only Requires symptomatic treatment is:
- Flu syndrome of fever, chills and pain bone
- Abdominal syndrome of abdominal pain, nausea, no appetite, vomiting sometimes
diarrhea
- Skin syndrome such as redness itching
- Rare but rare adverse events are: Hepatitis induced drug or jaundice, when things
happen. The OAT must be stopped first and Management according to TB
guidelines on the special circumstances
- Purpura, acute hemolytic anemia, shock and kidney failure. When any of these
symptoms occur, Rifampicin should be stopped immediately and do not given
again even though the symptoms have been disappeared
 - Respiratory syndrome characterized by tightness breath
- Rifampicin can cause redness in water sweat, tears, saliva. The red color occurs
due to the metabolic processes of the drug and not dangerous. This should be
notified to sufferers to be understood and not to worry.
c. Pyrazinamide
The main side effect is drug-induced hepatitis (Management according to TB
guidelines in special circumstances). Joint pain can also occur (give aspirin) and
sometimes Can cause Gout arthritis attacks, this is it possibly due to reduced excretion
and accumulation of uric acid. Sometimes reactions occur fever, nausea, redness and
other skin reactions.
d. Etambutol
Etambutol may cause vision impairment. In the form of reduced sharpness, color
blindness for color Red and green. Nevertheless ocular poisoning depends on the dose
used, rarely occurs when the dose is 15-25 mg / kg BW per day or 30 mg / kgBB
given 3 times a week. Impaired vision Will return to normal within a few weeks after
the drug stopped. Ethambutol should not be given to children because the risk of
ocular damage is difficult to detect
e. Streptomycin
The main side effect is the eighth nerve damage Which is related to balance and
hearing. The risk of these side effects will increase with Increased dose used and age
of the patient. The risk will increase in patients with impaired function of renal
excretion. Symptoms of side effects are looks are ears ring (tinnitus), dizziness and
Lose balance. This situation can be recovered when the drug is immediately stopped
or the dose is reduced by 0.25 gr. If Treatment is continued then the balance of the
equilibrium device the more severe and persistent (loss of balance and deaf).
Hypersensitivity reaction occasionally takes the form of a fever Arise suddenly
accompanied by headache, vomiting and erythema on the skin. Temporary and mild
side effects (rare happens) like a tingling around the mouth and ear the ringing may
occur immediately after the injection. When this reaction interferes then the dose can
be reduced 0.25gr streptomycin can penetrate the placental barrier so that should not
be given to pregnant women because they can damage the fetal hearing nerve.

Treatment of drug side effects:

Light side effects such as gastric disorders can be treated symptomatically

Disorders due to pyrazinamide can be treated with administration of salicylate /
allopurinol.
Patients with hypersensitive reactions such as rash on the skin that is generally
caused by INH and Rifampicin, may be administered low doses and desensitization
with enhanced dosage slowly with close supervision. This desensitization can not be
done against other drugs
The abnormality that should be discontinued treatment is Thrombocytopenia, shock
or renal failure due to rifampicin, impaired vision due to ethambutol, nervous Vill
 disorders due to streptomycin and exfoliative dermatitis and agranulocytosis due to
thiacetazone
If something medication should be replaced then the alloy should be changed until
the necessary treatment period reconsidered well.

Complication of Tuberculosis
Tuberculosis in lungs if not handled properly will cause complications.Complications that
occur patients divided into two, namely:

1. Early complications: : pleuritis, pleural effusion, empyema.

2. Complications at an advanced stage:

- Massive hemoptysis (bleeding from the lower airway) that can resulting in death due
to airway obstruction or shock hypovolemic
- Lobes collapse due to duct blockage
- Bronchietaxis (local bronchial dilation) and fibrosis (formation connective tissue in
the recovery or reactive process) of the lung
- Spontaneous pneumothorax, spontaneous collapse due to the bulls broken
- The spread of infection to other organs such as brain, bone, joints, kidneys, etc