Transcript Guidelines for chemotherapy of tuberculosis in Taiwan

Guidelines for
chemotherapy of
tuberculosis in Taiwan
馬偕紀念醫院 一般內科及感染科
主治醫師 曾祥洸
2005-3-9
Infectious Disease Society of Taiwan
The Society of Tuberculosis, Taiwan
Medical Foundation in Memory of
Dr. Deh-Lin Cheng
(J Microbiol Immunol Infect 2004;37:282-384)
Foundation of Professor Wei-Chuan Hsieh
for Infectious Diseases Research and
Education
CY Lee’s Research Foundation for Pediatric
Infectious Diseases and Vaccines
Three principles for the guidelines



1. From the viewpoint of primary care
physician
2. Antimicrobial agents recommended
already marketed in Taiwan
3. Base on academic principles rather
than the regulation of the Bureau of
National Health Insurance
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
New Case
Pulmonary tuberculosis

Drugs of choice for New case
•
•

1. Standard regimen: (total 6 months)
• INH+RIF+EMB+PZA
• Then INH+RIF+EMB
for 2 months,
for 4 months
2. Fixed-dose combinations: (total 6 months)
• Rifater+EMB
• Then Rifinah+EMB
for 2 months
for 4 months
cavitations on initial chest X ray
and/or positive cultures at completion of initial
2 months’ treatment,
 extend treatment to total 9 months.
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Retreatment
Pulmonary tuberculosis

Drugs of choice for
Retreatment (total 8 months)
• 1. Relapse 2. Default 3. Failure
• INH+RIF+EMB+PZA+IA for 3 months,
• Then INH+RIF+EMB for 5 months
IA: Injectable aminoglycosides include streptomycin,
kanamycin, and amikacin, and should be
administered in the initial 2 months of treatment
Retreatment
1. Relapse is defined as a patient who
develops active tuberculosis (by culture,
clinical or radiological deterioration) after
completion of anti-tuberculous therapy.
2. Default is defined as interruptions in therapy
of longer than 2 months.
3. Failure is defined as continued or recurrent
positive cultures after 4 months of treatment
in patients with assured adherence to the
prescribed anti-tuberculous regimen.
Pulmonary tuberculosis


Culture and susceptibility testing should
be done immediately and regimen
should be tailored to susceptibility testing
results.
Referral to specialists in Infectious
diseases, chest medicine or experts on
tuberculosis is recommended.
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Drugs Resistance
and Drugs Intolerance
Drug resistance to INH

RIF+EMB+PZA
for 6 months

RIF+EMB+PZA
+IA
for 6 months
Drug intolerance to INH

RIF+EMB+PZA
for 6 months
Drug resistance to RIF

INH+EMB+PZA
for 9-12 months

INH+EMB+PZA
+IA
+/- FQ
for 9 months

Fluroquinolones
include ofloxacin,
ciprofloxacin and
levofloxacin.
Drug intolerance to RIF

INH+EMB+PZA
for 9-12 months

INH+EMB+PZA
+IA
+/- FQ
for 9 months

Fluroquinolones
include ofloxacin,
ciprofloxacin and
levofloxacin.
Drug resistance to EMB

INH+RIF+PZA
for 2 months,
then
INH+RIF
for 4 months
(total 6 months)

--
Drug intolerance to EMB

INH+RIF+PZA
for 2 months,
then
INH+RIF
for 4 months
(total 6 months)

--
Drug resistance to
INH, RIF (MDR-TB):

EMB
+PZA
+IA
+FQ
+TBN (本院無)
(prothionamide)
for 18-24 months*

--
*Treatment duration is
a total of 18 months
after sputum
conversion.
Drug resistance to
INH, RIF, EMB (MDR-TB):

PZA
+IA
+FQ
+TBN (本院無)
(prothionamide)
+PSA (本院無)
for 18-24 months*

--
*Treatment duration is
a total of 18 months
after sputum
conversion.
Drug intolerance to PZA

INH+RIF+EMB
for 9 months

--
Drug intolerance to
INH, RIF :

EMB
+PZA
+IA
+FQ
+TBN (本院無)
(prothionamide)
for 18-24 months*

--
*Treatment duration is
a total of 18 months
after sputum
conversion.
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
3 Special situations
Liver function impairment
and/or liver cirrhosis

RIF+EMB+PZA
for 6 months

RIF+EMB+IA+FQ
for 12-18 months
Or
Or
INH+RIF+EMB
for 9 months
EMB+TBN (本院無)
(prothionamide)
+IA+FQ
for 18-24 months
Renal function impairment
is defined as Ccr<30mL/min or ESRD

INH+RIF+
EMB*+PZA*
for 2 months
then
INH+RIF+ EMB*
for 4 months
(total 6 months)

INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 4 months*
*Intermittent dosing
(total 6 months)
Pregnancy or breastfeeding

INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 4 months
(total 6 months)

INH+RIF+EMB
for 9 months
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Dosage of
antituberculous agents
(for adult only)
Dosage of antituberculous
agents (for adult only)

INH (100 mg)


RIF (150; 300 mg)


EMB (400 mg)
EMB*

PZA (250 mg)
PZA*
5 mg/kg BW qd
(maximum 300mg)
10 mg/kg BW qd
(maximum 600mg)

15-25 mg/kg BW qd
15-25 mg/kg BW qod

15-30 mg/kg BW qd
(maximum 2 g)
12-25 mg/kg BW qd
Intermittent dosing (3 times
weekly) after hemodialysis

INH (100mg)

900mg

RIF (150; 300 mg)

600mg

EMB (400 mg)

15-25 mg/kg BW

PZA (250 mg)

25-35 mg/kg BW
Dosage of antituberculous
agents (for adult only)

Streptomycin (1g)
amikacin (250mg)
kanamycin (本院無)

Ciprofloxacin (250mg)  500-750 mg bid
Levofloxacin (100mg)  500mg qd
Ofloxacin (本院無)
 400mg bid

15 mg/kg BW qd
Dosage of antituberculous
agents (for adult only)

TBN (本院無)

PAS (本院無)

15-20 mg/kg BW,
divided to bid-tid
(maximum 1 g)

200 mg/kg BW,
divided to bid-qid
Dosage of antituberculous
agents (for adult only)



Rifater
(INH 80 +RIF 120
+PZA 250)
Rifinah-300 (本院無)
(INH 150 +RIF 300 )

1 tab/10kg BW qd
(maximum 5 tab)

2 tab qd,
if BW > 50 kg BW
Rifinah-150 (本院無)
(INH 100 +RIF 150 )

3 tab qd,
if BW < 50 kg BW
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Extrapulmonary
tuberculosis
Pleurisy, Lymphadenitis, Peritonitis
(intestinal disease), Pericarditis,
Genito-urinary tract disease

INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 4 months
(total 6 months)

--
Bone and joint diseases,
pleural empyema

INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 7 months
(total 9 months)

--
Meningitis, CNS disease

INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 10 months
(total 12 months)

--
Steroids


Prednisolone < 1 mg/kg BW qd or
equivalent for a minimum of 3 weeks
Recommended in
Pericarditis
Meningitis
CNS disease
Topics not included




1. TB - HIV coinfection
2. Drug-drug interaction
3. Other antituberculosis drugs (rifabutin,
cycloserine)
4. Treatment of the pediatric population
Guidelines for
chemotherapy of
tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Thanks for yours attention!