PHTHISIOLOGY

1. PHTHISIOLOGY Treatment of patient with TB

2. Treatment of TB Disease • Treating TB disease benefits both the person who has TB and the community • For patient, prevents disability and death; restores health • For community, prevents further transmission of TB • TB disease must be treated for at least 6 months; in some cases, treatment lasts longer • e.g., patients with cavities on chest x-ray and positive sputum cultures at 2 months should have treatment extended to 9

3. Aims of treatment of TB • Cure the patient • Prevent death/disability • Prevent relapse • Prevent Transmission to others

4. High rateof patients recovery Cure 85% or more infectious (MBT+) patients

5. Principles of Tuberculosis Treatment • Regimens Must Contain Multiple Drugs • Drugs Must be Taken Regularly • Treatment Must be Continued for Sufficient Time (Minimal Acceptable Duration of Treatment = 6 Months) • Compliance. You should to known if the patient take medicine

6. Principles of Tuberculosis Treatment • Any Regimen is Irrelevant if Drugs Do Not Enter The Patients Body. Promoting and Monitoring Adherence to The Drug Regimen Are Essential For Treatment To be Successful

7. Principles of Tuberculosis Treatment • The World health Organization • Directly Observed Therapy • (DOT; DOTS) • STOP TB, etc.

8. Treatment of TB Disease (2) Initial Phase • First 8 weeks of treatment • Most bacilli killed during this phase • 4 or more drugs used After weeks of TB disease treatment • Bacilli remaining after initial phase are treated with at least 2 drugs Occurs when treatment is not • continued for long enough • Surviving bacilli may cause TB disease at a later time Continuation Phase Relapse

9. Classification of antitubercular medication • Antitubercular medications of I line: isoniazid, rifampin, streptomycin, ethambutol, pyrasinamide. • Antitubercular medications of II line: ethionamide, amikacin, kanamycin, cycloserin, ofloxacin, ciprofloxacin, capreomycin, sodium para-aminosalicylic acid.

10. Classification of antitubercular medication • Classification of the International antitubercular union: • Most effective medications: • Synthetic isoniazid (hydrazide of isonicotinic acid) • Antibiotic rifampin • Medications of moderate effectiveness: • Antibiotics: streptomycin, kanamycin, florimycin (viomycin), cycloserin. • Synthetic medications: ethambutol, ethionamide, prothionamide, pyrazinamide (thisamid). • Least effective medications: • Synthetic medications PASK, Tibon (Thioacetazon).

11. Treatment of TB Disease (3) • Initial regimen should contain the following four drugs: • Isoniazid (H, INH) • Rifampicin (R, RIF) • Pyrazinamide (Z, PZA) • Ethambutol (E, EMB)

12. Treatment of TB Disease (4) • Treatment must contain multiple drugs to which organisms are susceptible • Treatment with a single drug can lead to the development of drug-resistant TB

13. Preventing Drug Resistance (1) • Drug resistance can develop when patients are prescribed an inappropriate regimen • TB disease must be treated with at least 2 drugs to which bacilli are susceptible • Using only one drug can create a population of tubercle bacilli resistant to that drug • Adding a single drug to failing regimen may have the same effect as only using one drug

14. Preventing Drug Resistance (2) • Resistance can develop when patients do not take drugs as prescribed • Patients do not take all of their pills • Patients do not take pills as often as prescribed

15. Preventing Drug Resistance (3) • Factors that increase chance of patient having or developing drug-resistant TB: • Patient has spent time with someone with active drug-resistant TB disease • Patient does not take their medicine regularly • Patient does not take all of their medicine

16. Preventing Drug Resistance (4) • Factors that increase chance of patient having or developing drug-resistant TB (cont.): • Patient develops active TB disease after having taken TB medicine in the past • Patient comes from area of the world where drug-resistant TB is common

17. Treatment of TB Disease • Treatment Regimens and Dosage Recommendations

18. TB Treatment Regimens (CAT. 1) • New case of Pulmonary TB smear positive • New case of Pulmonary TB smear negative with extensive pulmonary involvement (more than 2 segments) • New case of extrapulmonary TB: severe forms

19. TB Treatment Regimens (CAT. 1) • Intensive phase 2HRZS(E) 2 months INH RIF PZA STR (EMB) 60 doses (2 months)

20. TB Treatment Regimens (CAT. 1) • Continuation phase 4HR or 4H3R3 4 months INH RIF daily or 4 months INH RIF 3 times per week 120 doses (4 months)

21. TB Treatment Regimens (CAT. 2) • TB patients treated in the past: • Treatment failure • Relapse • Treatment interruption (more than 2 months)

22. TB Treatment Regimens (CAT. 2) • Intensive phase 2HRZES/1HRZE INH RIF PZA EMB STM 60 doses (2months) + INH RIF PZA EMB 30 doses (1 months)

23. TB Treatment Regimens (CAT. 2) • Continuation phase 5H3R3E3 or 5HRE 5 months INH RIF EMB 3 times per week (66 dosages) or 5 months INH RIF daily 150 doses (5 months)

24. TB Treatment Regimens (CAT. 3) newly diagnosed TB but unconfirmed by culture/bacterioscopy local or extended pulmonary tuberculosis extrapulmonary tuberculosis and do not belong to the 1st category

25. TB Treatment Regimens (CAT. 3) • Intensive phase 2HRZ or 2H3R3Z3 INH RIF PZA EMB 60 doses (2 months)

26. TB Treatment Regimens (CAT. 3) • Continuation phase 4HR or 4H3R3 4 months INH RIF daily (120 dosages) or 4 months INH RIF 3 times per week (54 dosages)

27. TB Treatment Regimens (CAT. 4) • Chronic case • Multidrug resistant TB

28. TB Treatment Regimens (CAT. 4) • Individual regimens • Using 2 line drugs

29. Special Considerations (1) • TB medical experts should be consulted for complicated and challenging TB treatment issues • Consultation can be provided by National TB Programs and/or the TB Regional Training and Medical Consultation Centers

30. Special Considerations (2)People Living with HIV • Treatment for HIV patients is generally the same as for those without HIV-infection with two exceptions: • Once weekly INH and rifapentine in continuation phase should not be used • Patients with advanced HIV should be treated daily or three times weekly in the initial and continuation phase

31. Special Considerations (3)People Living With HIV • Patients should receive a minimum of 6 months treatment and be closely monitored • Continuation phase may need to be extended to 7 months (9 months total treatment time), if patient is responding slowly to treatment

32. Special Considerations (4)People Living With HIV • DOT should be provided for all TB patients living with HIV • If TB patient is living with HIV and on ARV: • It is important to be aware of the interaction of RIF with some ARV drugs • Rifabutin has fewer drug interaction problems and may be used as a substitute for RIF for some patients

33. Special Considerations (5) Pregnant Women • Treatment should begin as soon as TB disease is diagnosed • Preferred initial regimen is INH, RIF, and EMB for at least 9 months • Drugs that should not be used • Pyrazinamide (PZA) • Streptomycin (SM) • Vitamin B6 supplements are recommended for all pregnant women taking INH

34. Special Considerations (6)Breastfeeding • Women being treated with first-line TB drugs should not be discouraged from breastfeeding • Only small concentration found in breast milk • Not harmful to infant

35. Special Considerations (7)Breastfeeding • Drugs in breast milk should not be considered effective treatment for TB disease for infant • Vitamin B6 supplements are recommended for breastfeeding women

36. Special Considerations (8)Children • Infants and children younger than 4 years should start TB treatment as soon as possible • Recommended treatment: • 6 months • 3 drugs (INH, RIF, PZA) in initial phase

37. Special Considerations (9)Children • EMB is not recommended for children unless TB is resistant to INH, child is a contact of patient with INH-resistant TB, or TB manifestation is similar to TB in adults (e.g., cavities or extensive upper-lobe infiltrates) • Pills may have to be crushed or given in liquid form • It is not recommended to treat children 3 times a week

38. Special Considerations (10)People with Extrapulmonary Disease • Regimens used for treating pulmonary TB are also effective for treating extrapulmonary TB • Infants and children with miliary TB (disseminated TB), bone and joint TB, or TB meningitis should receive at least 9-12 months of treatment

39. Alternative Treatment Regimens (1)Drug-Resistant TB • Alternative regimens should be used for treating drug-resistant TB • Treatment of drug-resistant TB should always be done under the supervision of a medical expert

40. Alternative Treatment Regimens (2)Drug-Resistant TB • INH-resistant TB can be treated with the following regimens: • RIF, EMB, and PZA for 6-9 months • RIF and EMB for 12 months

41. Alternative Treatment Regimens (3)MDR TB • Resistant to INH and RIF • More difficult to treat than drug-susceptible TB • Drugs that can be used are less effective and are more likely to cause adverse reactions • Treatment can last longer than 2 years or more • Surgery is sometimes use to remove infected site

42. Alternative Treatment Regimens (4)Extensively Drug-Resistant TB (XDR TB) • XDR TB is resistant to INH, RIF, plus any fluoroquinolones, and at least one injectable second-line drug (e.g., amikacin, kanamycin, or capreomycin) • XDR TB patients have less effective treatment options • XDR TB is very difficult to treat

43. Alternative Treatment Regimens (5)XDR TB • Successful outcomes for patient depend greatly on: • Extent of drug resistance • Severity of disease • Whether patient’s immune system is compromised

44. Treatment and Monitoring Plan • Adverse Reactions

45. Treatment and Monitoring Plan • Every TB patient should have a specific treatment and monitoring plan developed in collaboration with local health department • Plan should include: • Description of treatment regimen • Methods of: • Monitoring for adverse reactions • Assessing and ensuring adherence to treatment • Evaluating treatment responce

46. Monitoring Adverse Reactions (1) • Patients should have baseline blood and vision tests to detect problems that may complicate treatment • Children only need vision tests, unless there are other medical conditions that may complicate treatment

47. Monitoring Adverse Reactions (2) • Follow-up tests should be done periodically if: • Results of baseline tests indicate abnormalities • Patient has symptoms that may be due to adverse reactions

48. Monitoring Adverse Reactions (3) • Patients should be educated about symptoms caused by adverse reactions to drugs • Patients should be seen by clinician at least monthly during treatment and evaluated for possible adverse reactions • Public health workers who have regular contact with patients should ask about adverse reactions to treatment

49. Monitoring Adverse Reactions (4) • If patient has symptoms of a serious adverse reaction, HCW should: • Instruct patient to stop medication • Report situation to clinician and arrange for medical evaluation • Note symptoms in patient’s record

50. Monitoring Adverse Reactions (5) • INH • Peripheral neuropathy • Tingling sensation in hands and feet • Serious