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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).

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Guidelines for chemotherapy of tuberculosis in Taiwan

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  1. 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

  2. Infectious Disease Society of TaiwanThe Society of Tuberculosis, TaiwanMedical 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 EducationCY Lee’s Research Foundation for Pediatric Infectious Diseases and Vaccines

  3. 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

  4. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) New Case

  5. Pulmonary tuberculosis • Drugs of choice for New case • 1. Standard regimen: (total 6 months) • INH+RIF+EMB+PZA for 2 months, • ThenINH+RIF+EMB for 4 months • 2. Fixed-dose combinations: (total 6 months) • Rifater+EMB for 2 months • Then Rifinah+EMB for 4 months • cavitations on initial chest X ray and/or positive cultures at completion of initial 2 months’ treatment,  extend treatment tototal 9 months.

  6. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) Retreatment

  7. 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

  8. 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.

  9. 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.

  10. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) Drugs Resistance and Drugs Intolerance

  11. RIF+EMB+PZA for 6 months RIF+EMB+PZA +IA for 6 months Drug resistance to INH

  12. RIF+EMB+PZA for 6 months Drug intolerance to INH

  13. INH+EMB+PZA for 9-12 months INH+EMB+PZA +IA +/- FQ for 9 months Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin. Drug resistance to RIF

  14. 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

  15. INH+RIF+PZA for 2 months, then INH+RIF for 4 months (total 6 months) -- Drug resistance to EMB

  16. INH+RIF+PZA for 2 months, then INH+RIF for 4 months (total 6 months) -- Drug intolerance to EMB

  17. 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 (MDR-TB):

  18. 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 resistance to INH, RIF, EMB (MDR-TB):

  19. INH+RIF+EMB for 9 months -- Drug intolerance to PZA

  20. 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 intolerance to INH, RIF :

  21. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) 3 Special situations

  22. RIF+EMB+PZA for 6 months Or INH+RIF+EMB for 9 months RIF+EMB+IA+FQ for 12-18 months Or EMB+TBN (本院無) (prothionamide) +IA+FQ for 18-24 months Liver function impairment and/or liver cirrhosis

  23. 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) Renal function impairment is defined as Ccr<30mL/min or ESRD

  24. INH+RIF+EMB+PZA for 2 months then INH+RIF+EMB for 4 months (total 6 months) INH+RIF+EMB for 9 months Pregnancy or breastfeeding

  25. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) Dosage of antituberculous agents (for adult only)

  26. 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 BWqod 15-30 mg/kg BW qd (maximum 2 g) 12-25mg/kg BW qd Dosage of antituberculous agents (for adult only)

  27. INH (100mg) RIF (150; 300 mg) EMB (400 mg) PZA (250 mg) 900mg 600mg 15-25 mg/kg BW 25-35 mg/kg BW Intermittent dosing (3 times weekly) after hemodialysis

  28. Streptomycin (1g) amikacin (250mg) kanamycin (本院無) Ciprofloxacin (250mg) Levofloxacin (100mg) Ofloxacin (本院無) 15 mg/kg BW qd 500-750 mg bid 500mg qd 400mg bid Dosage of antituberculous agents (for adult only)

  29. 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)

  30. Rifater (INH 80 +RIF 120+PZA 250) Rifinah-300 (本院無) (INH 150 +RIF 300 ) Rifinah-150 (本院無) (INH 100 +RIF 150 ) 1 tab/10kg BW qd (maximum 5 tab) 2 tab qd, if BW > 50 kg BW 3 tab qd, if BW < 50 kg BW Dosage of antituberculous agents (for adult only)

  31. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) Extrapulmonary tuberculosis

  32. INH+RIF+EMB+PZA for 2 months then INH+RIF+EMB for 4 months (total 6 months) -- Pleurisy, Lymphadenitis, Peritonitis (intestinal disease), Pericarditis, Genito-urinary tract disease

  33. INH+RIF+EMB+PZA for 2 months then INH+RIF+EMB for 7 months (total 9 months) -- Bone and joint diseases, pleural empyema

  34. INH+RIF+EMB+PZA for 2 months then INH+RIF+EMB for 10months (total 12 months) -- Meningitis, CNS disease

  35. Steroids • Prednisolone < 1 mg/kg BW qd or equivalent for a minimum of 3 weeks • Recommended in Pericarditis Meningitis CNS disease

  36. Topics not included • 1. TB - HIV coinfection • 2. Drug-drug interaction • 3. Other antituberculosis drugs (rifabutin, cycloserine) • 4. Treatment of the pediatric population

  37. Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384) Thanks for yours attention!

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