Transcript TB_8 - I-TECH

Unit 8: Complications and
Special Situations
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
Objectives
At the end of this unit, participants will be able to:
• Manage Category I, II, and second-line therapy
in special situations:
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Pregnancy
Breastfeeding
Rash
Liver disease
Kidney Disease
Unit 8: Complications and Special Situations
• Peripheral
neuropathy
• Psychiatric illness
and MDR
• Paradoxical reactions
Slide 8-2
Pregnancy
• Every woman of child bearing age should be asked if
she is pregnant prior to starting anti-TB treatment
• Successful outcome of pregnancy largely depends
on successful completion of anti-TB treatment
• Category I- drugs are safe in pregnancy
• Category II- Streptomycin should be avoided if
possible as it can cause ototoxicity of the foetus
Unit 8: Complications and Special Situations
Slide 8-3
Pregnancy: Category IV
If a woman is pregnant, if possible:
• Avoid the first trimester and start treatment
during the 2nd or 3rd trimester
• Avoid amikacin (and streptomycin) until after
delivery (fetal ototoxicity possible)
• Avoid ethionamide (teratogenic in animals)
Unit 8: Complications and Special Situations
Slide 8-4
Breastfeeding
• Women on Category I
and II Regimens should
continue breastfeeding
• If mother has smear+
TB and baby does not
have active TB, give
baby INH, as
appropriate for weight,
for 6 months followed
by BCG vaccination
Unit 8: Complications and Special Situations
Courtesy of: Jeanne Raisler
Slide 8-5
Rash in TB Treatment (1)
• Before attributing a skin symptom or rash to
TB medications, assess
• Was it present before TB therapy began?
• Is it a condition unrelated to TB treatment?
• Many persons on TB treatment also have HIV
• Many people with HIV have skin conditions
• ARVs can also cause skin conditions, especially
NVP
Unit 8: Complications and Special Situations
Slide 8-6
Rash in TB Treatment (2)
• Mild to Moderate rashes
• Skin rash with mild itching
• No blisters or mucous membrane involvement
• Management
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Consider other causes (scabies, etc.)
Aqueous cream, Calamine skin lotion
May need to stop TB medications
Chlorpheniramine 4 mg tds, or
Promethazine 25-50 mg nocte
Unit 8: Complications and Special Situations
Slide 8-7
Mild to Moderate Rash
Mild
Rash
Unit 8: Complications and Special Situations
Source: I-TECH, 2006.
Slide 8-8
Severe Rash
Rash with:
• Persistent itchiness
• Mucous membrane involvement and/or
• Blistering
• Urticaria (hives)
Unit 8: Complications and Special Situations
Slide 8-9
Severe Rash
Unit 8: Complications and Special Situations
Source: I-TECH, 2006.
Slide 8-10
Severe Rash Management (1)
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Stop all TB drugs together
Hospitalise the patient
Give IV fluids as required
Consider antibiotics for severe
desquamation/exfoliation
• Treat like a burn
• Consider the use of steroids
Unit 8: Complications and Special Situations
Slide 8-11
Severe Rash Management (2)
• Most patients can wait for the rash to resolve
before resuming TB treatment
• If the patient has life-threatening TB as well as
life-threatening rash, may provide at least 2
TB drugs (3 drugs preferred) the patient has
not taken before until the rash subsides
Unit 8: Complications and Special Situations
Slide 8-12
Treatment After Rash (1)
If it is not obvious which caused the reaction,
which is often the case, re-introduce TB
medications in a step-wise fashion
• Gradually increase the dose of each medication
• If no reaction, continue the medication and
gradually increase the dose of the next medication
• Use in reverse order of likelihood of cause of rash
Unit 8: Complications and Special Situations
Slide 8-13
Schedule for
Reintroduction of Anti-TB Drugs
Day
Drug and dose
1
INH 25 mg
2
INH 50 mg
3
INH 100 mg
4
INH 200 mg
5
INH 300 mg*
6
INH 300 mg + R 150 mg
7
INH 300 mg + R 300 mg
8
INH 300 mg + R 450 mg
9
INH 300 mg + R 600 mg*
10
INH 300 mg + R 600 mg + E 400 mg
11
INH 300 mg + R 600 mg + E 800 mg
12
INH 300 mg + R 600 mg + E 1200 mg*
13
INH 300 mg + R 600 mg + E 1200 mg + Z 500 mg
14
INH 300 mg + R 600 mg + E 1200 mg + Z 1000 mg
15
INH 300 mg + R 600 mg + E 1200 mg + Z 1500 mg
16
INH 300 mg + R 600 mg + E 1200 mg + Z 2000 mg*
Unit 8: Complications and Special Situations
Slide 8-14
Treatment After Rash (2)
• If gradual reintroduction succeeds without a
recurrence of rash, can continue treatment
• If the offending drug causes a reaction,
suspend it and replace the offending drug with
another agent
• May leave out pyrazinamide, ethambutol or
streptomycin
• Get expert advice; substitutions may require
longer duration of therapy
Unit 8: Complications and Special Situations
Slide 8-15
Liver Disease
• Three important issues complicate therapy:
• Hepatotoxicity of anti-TB drugs
• Acute liver disease with concurrent TB
• Chronic liver disease with concurrent TB
• Provided there is no clinical evidence of
chronic liver disease, ATT is safe in patients
with hepatitis virus carriage, history of acute
hepatitis or excessive alcohol consumption
Unit 8: Complications and Special Situations
Slide 8-16
Acute Hepatitis
Prior to TB Treatment
• Evaluate the cause:
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Viral (Hepatitis A, Hepatitis B)
Alcohol
ARVs
Traditional medicines
Other toxins
• If possible, await resolution of acute hepatitis
before starting TB treatment
Unit 8: Complications and Special Situations
Slide 8-17
Acute Hepatitis
Prior to TB Treatment (2)
• Consult TB expert
• Initial phase: SE for 3 months
• Continuation phase:
• RH for 6 months OR
• SE for 9 additional months
• Avoid Z, H, R and Eth (ethionamide) during
acute hepatitis
Unit 8: Complications and Special Situations
Slide 8-18
Established Chronic Liver
Disease Prior to TB Treatment
• Evaluate the cause
• Viral: Hepatitis B, Hepatitis C
• Alcohol
• Disseminated TB
• Avoid PZA
• Requires close monitoring
• Liver function tests
• Sputum samples
• Experienced TB doctor
Unit 8: Complications and Special Situations
Slide 8-19
TB Treatment with
Chronic Liver Disease
• Preferred option
• Initial: 2 months RHES
• Continuation: 6 months RH
• Second option
• Initial: 2 months RES
• 10 months RE
• Third option
• Initial: 2 months HES
• Continuation: 10 months HE
Unit 8: Complications and Special Situations
Slide 8-20
Hepatotoxicity
• Symptoms: Fever, malaise, right upper
quadrant abdominal pain, nausea, vomiting,
loss of appetite
• Signs:
• ALT or AST more than 3x increased if symptoms
of hepatitis are present, or more than 5x increased
without symptoms
• Bilirubin or alkaline phosphatase more than 2x
increased
• Jaundice
Unit 8: Complications and Special Situations
Slide 8-21
TB Drugs & Hepatotoxicity
Hepatotoxic
NOT Hepatotoxic
• Pyrazinamide and isoniazid
are the most common
causes
• Pyrazinamide causes the
most severe
• Rifampicin hepatotoxicity is
less common and less
severe
• Ethionamide
• Ethambutol
• Streptomycin
Unit 8: Complications and Special Situations
Slide 8-22
Hepatotoxicity
• Try to rule out other causes of acute liver disease
before attributing it to the TB treatment
• In hepatotoxicity, stop all TB drugs until the patient
improves
• In case of severe TB, consider using “liver sparing
regimen” (Ethambutol, streptomycin, and
Ciprofloxacin)
• Admit patients to the hospital if unable to maintain
hydration or if hepatic failure develops
Unit 8: Complications and Special Situations
Slide 8-23
Acute Hepatitis:
During TB Treatment
• Rare
• Decision whether to stop or continue anti-TB
treatment requires good clinical judgment
• Safest option in acute hepatitis not due to TB
is to give streptomycin and ethambutol until
the hepatitis has resolved (for a maximum of 3
months) followed by a continuation phase of
INH and rifampicin for 6 months
Unit 8: Complications and Special Situations
Slide 8-24
Treatment After Hepatotoxicity (1)
• When hepatitis has resolved, reintroduce
therapy
• If lab tests are not available, wait until 2 weeks
after the jaundice ends
• If lab tests are available wait until AST/ALT <
2x normal
• Stepwise fashion, starting with safest drugs
• Try to create a safe combination regimen
Unit 8: Complications and Special Situations
Slide 8-25
Reintroduction of
Drugs After Hepatoxicity
• Continue EMB, streptomycin, +/- ciprofloxacin
• INH 300 mg daily x 4 days
• If no symptoms, add
• Rifampicin 600 mg daily x 4 days
• If no symptoms, 2 options:
• Do not try PZA
• Try PZA
• D/C streptomycin and ciprofloxacin when back
on E, H, R
Unit 8: Complications and Special Situations
Slide 8-26
Treatment After Hepatotoxicity (2)
• Pyrazinamide toxicity
• 2 months RHES then 6 months RH
• Check sputum at 2, 5, and 7 months
• Pyrazinamide and isoniazid toxicity
• 2 months RES then 10 months RE
• Check sputum at 2, 5, 8, and 11 months
• Pyrazinamide and rifampicin toxicity
• 2 months HES then 10 months HE
• Check sputum at 2, 5, 8, and 11 months
Unit 8: Complications and Special Situations
Slide 8-27
Renal Disease
• Some patients with active TB will have renal
disease due to either TB in the urinary tract or
another condition
• Adjust dose of ethambutol based on creatinine
clearance if renal disease is suspected
• Avoid streptomycin unless specialist care is
available
• Safest regimen: 2HRZ/4HR
Unit 8: Complications and Special Situations
Slide 8-28
Key Points
• Careful assessment is needed to distinguish drug
reactions from other conditions
• Successful management of adverse drug reactions is
necessary for patient health and integrity of the TB
control program
• Treatment of patients with chronic liver or kidney
disease may require changes in regimen or dosing
• Issues with category II regimen and second-line
treatment are more complex
Unit 8: Complications and Special Situations
Slide 8-29