Transcript When you can’t use RIPE

When you can’t use RIPE
Alternative Regimens:
When INH resistant or intolerant
• 12 controlled BMRC trials: 2X higher relapse rate
overall in INH resistant patients, but rate of relapse
dropped to 2% if 6 months INH/Rif/PZA/EMB or Strep.
• Current ATS/CDC/IDSA TB Treatment guidelines
recommend Rif/PZA/EMB +/- FQN (fluoroquinolone)
• SF experience (Dr. Kawamura): Relapse rate for INH
resistant disease no greater than pan sensitive cases,
both 2%
– Only 41% completed the 6 month regimen due to
intolerance of PZA for that long
HK Chest Serv. BMRC. Trial of 6 and 9 month regimens … Am Rev Respir Dis, 1987
Cattamanchi A, et.a. RX outcomes in INH Mono-R TB. CID, 2009
Alternative Regimens:
When INH resistant or intolerant
• If unable to use the PZA for 6 months or if PZA
resistant in addition to INH R:
– Rifampin, EMB, and Moxifloxacin or Levofloxacin
for 9-12 months
• If INH and EMB resistant:
– Rifampin, PZA, and Moxi or Levo for 9-12 months
Drug Resistant TB: A Survival Guide, 2nd Ed., 2008
Alternative Regimens:
PZA mono resistance
• This is most commonly found in M.bovis
disease
• Can use 9 month regimen of INH and Rifampin
• Will have typically been on EMB as part of 4
drug regimen before DSTs known
Alternative Regimens:
Rifampin resistance or intolerance
• If rifampin mono-resistant or intolerant;
– INH, PZA, EMB +/- FQN for 9-12 months
(ATS/IDSA/CDC, 2003)
– Can strengthen regimen with injectable drug for
initial 2 months in extensive disease
• If rifampin + additional resistance or
intolerance but not to INH;
– INH + at least 2 additional agents (including a
FQN) to which organism is sensitive for 12-18
months
Alternative Regimens:
MDR TB
• Current recommendations are to use 4-6
drugs to which organism is sensitive
– At least one injectable (Amikacin, kana, capreo,
strep only if known sensitive)
– A FQN (Levo or Moxi)
– 2-4 additional drugs
– 18-24 months treatment after culture conversion