Module 5:

Principles of Treatment

Session Overview

Aims of TB Treatment
General Principles
Treatment Guidelines
 Learning Objectives

Describe 3 basic principles of TB

treatment
Explain the difference between the 4
treatment categories (Cat I-IV)
Understand and describe when and
why a regimen may be extended
 Aims of TB Treatment

Cure the patient of TB

Prevent death from active TB or its
latent effects
Prevent relapse of TB
Decrease transmission of TB to others
Prevent the development of acquired
resistance
Fundamental Responsibility and
Approach in TB Treatment

Assure that appropriate regimen is

prescribed by MOs

Ensure successful completion of therapy

(adherence)

Utilize directly observed therapy (DOT) as

standard-of-care
 Adherence

Nonadherence is a major problem in TB

control

Patient education is the most effective tool to

prevent defaultUSE IT!!

Use case management and directly observed

therapy (DOT) to ensure patients complete
treatment
Why Do Patients Default?

As their condition improves they may feel

better and decide they dont need meds
They may experience side effects
Forgetfulness/lack of a reminder!
Travel to cattle posts without refills
Difficulty getting to clinic b/c of
work/distance
 What is Case Management?

Assignment of responsibility within clinic to

oversee patient monitoring
-bacteriology
-DOT
-side effects

Systematic regular review of patient data

Plans in place to address barriers to

adherence BEFORE default occurs
 Directly Observed Therapy (DOT)

Health care worker watches patient swallow

each
-Dose of medication
-Every pill, every day
-Self-administered is NOT DOT

REMEMBER

DOT for all patients on all regimens

NO exceptions
 DOT in GhantsiCan you
identify the main elements?
 Directly Observed Therapy (DOT)

DOT can lead to reductions in relapse

and acquired drug resistance

Use DOT with other measures to promote

adherence

DOT is the key to CURE

Treatment of TB Disease
Factors Guiding Treatment Initiation

Epidemiologic information
e.g., circulating strains, resistance patterns
Clinical, pathological, chest x-ray findings
Microscopic examination of acid-fast bacilli
(AFB) in sputum smears
 Basic Principles of
Treatment

Determine the patients HIV status- this could save

their life!

Provide safest, most effective therapy in shortest

time

Multiple drugs to which the organisms are

susceptible

Never add single drug to failing regimen

Ensure adherence to therapy (DOT)

 Standard Treatment Regimen

Initial phase: standard four drug

regimens (INH, RIF, PZA, EMB), for 2
months
Continuation phase: additional 4
months
 Treatment of TB
for HIV-Negative Persons
2 months HRZE followed by 4HR

Four drugs in initial regimen always

- Isoniazid (INH)

- Rifampin (RIF)

- Pyrazinamide (PZA)

- Ethambutol (EMB) or streptomycin (SM)

(Streptomycin replaces Ethambutol in TB

meningitis)
 Treatment of TB
for HIV-Positive Persons

Management of HIV-related TB is complex

and patient care needs to be coordinated with
IDCC

HIV-infected patients already on ARVs who

develop TB should begin anti-TB meds
immediately
Patients on 1st line ARVs may start Category I
ATT.
Patients on ARV regimen with efavirenz
should be reviewed by a specialist.
If patient is on 2nd or 3rd line ARVs discuss
with specialist before starting ATT.
 Treatment of TB
for HIV-Positive Persons
HIV-infected TB patients should be
evaluated for ARVs immediately
Pts with CD4<=200 should start ARVs
within two weeks after start of ATT
Pts with CD4s>200 may defer until end of
ATT
 Extrapulmonary TB

In most cases, treat with same regimens

used for pulmonary TB

Bone and Joint TB, Miliary TB,

or TB Meningitis in Children

Treatment extended > 6 months

depending on site of disease

In TB meningitis Streptomycin replaces

Ethambutol
Infants and Children

Children
Children are at an increased risk for TB
disease
If the disease is severe (meningitis,
military TB, etc.) use Category I
treatment, SM replaces EMB in small
children
For less severe disease: treat with
category III regimen
In most cases, treat with same regimens
used for adults
Infants
Treat as soon as diagnosis is suspected
 Dosing of CPT in Children
Double
Single Strength
Age and weight Recommended Suspension strength
Child Tablet adult
of child daily dose 5ML syrup
100mg/20mg adult
=200mg/40 tablet
mg tablet 800mg/160m
400mg/80mg g

100mg
6 weeks to 6 sulfamethox
months asole/20mg
(<5kg) trimethoprim 2.5ml 1 tablet n/a n/a

200mg
6 months to 5 sulfamethox
years (5- asole/40mg
15Kg) trimethoprim 5ml 2 tablets 1/2 tablet n/a

400 mg
sulfamethox
6 to post asole/80mg
pubertal trimethoprim 10ml 4 tablets 1 tablet 1/2 tablet

800 mg
sulfamethox
Post pubertal asole/160mg
and Adults trimethoprim n/a n/a 2 tablets 1 tablet
 Multidrug-Resistant TB (MDR TB)

Presents difficult treatment problems

Lengthy, multi-drug regimen
Side effects common
Management complex

Treatment must be individualized

Clinicians unfamiliar with treatment of MDR

TB should seek expert consultation

Always use DOT to ensure adherence

 Multidrug-Resistant TB (MDR TB) Cont

6 months intensive treatment (always

including an injectable drug) followed
by at least an 18 month continuation
phase

Only specialist physicians at the

referral hospitals can initiate MDR
treatment
 Treatment Monitoring

Sputum smear microscopy for AFB at 2

months and 6 months
If positive at two months, repeat at 3

If still smear positive at 3 months,

continuation phase (4HR) is still started
while awaiting DST results

Continue drug-susceptibility tests if smear-

positive after 3 months of treatment
 Adverse Drug Reactions
Caused by Adverse Reaction Signs and Symptoms
Any drug Allergy Skin rash
Ethambutol Eye damage Blurred or changed vision
Changed color vision
Isoniazid, Hepatitis Abdominal pain
Pyrazinamide Abnormal liver function
or test
Rifampin results
Fatigue
Lack of appetite
Nausea
Vomiting
Yellowish skin or eyes
Dark urine
 Adverse Drug Reactions

Caused by Adverse Reaction Signs and Symptoms

Isoniazid Peripheral Tingling sensation in hands and
neuropathy feet
Pyrazinamide Gastrointestinal Upset stomach, vomiting, lack
intolerance of appetite
Arthralgia Joint aches
Arthritis Gout (rare)
Streptomycin Ear damage Balance problems
Hearing loss
Ringing in the ears
Kidney damage Abnormal kidney function test
results
 Common Adverse Drug
Reactions

Caused by Adverse Reaction Signs and Symptoms

Rifamycins Thrombocytopenia Easy bruising
Rifabutin Slow blood clotting
Rifapentine Gastrointestinal Upset stomach
intolerance
Rifampin
Drug interactions Interferes with certain
medications, such as birth
control pills, birth control
implants, and methadone
treatment
 Drug Interactions

Relatively few drug interactions substantially change

concentrations of antituberculosis drugs
Antituberculosis drugs sometimes change
concentrations of other drugs
-Rifamycins can decrease serum concentrations of
many drugs, (e.g., most of the HIV-1 protease
inhibitors), to subtherapeutic levels
-Isoniazid increases concentrations of some drugs
(e.g., phenytoin) to toxic levels