Module 5: Principles of Treatment Session Overview –Aims of TB Treatment –General Principles...
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Transcript of Module 5: Principles of Treatment Session Overview –Aims of TB Treatment –General Principles...
Module 5: Principles of Treatment
Session Overview
– Aims of TB Treatment – General Principles– Treatment Guidelines
Learning Objectives
• Describe 3 basic principles of TB treatment
• Explain the difference between the 4 treatment categories (Cat I-IV)
• Understand and describe when and why a regimen may be extended
Aims of TB Treatment
• Cure the patient of TB
• Prevent death from active TB or its latent effects
• Prevent relapse of TB
• Decrease transmission of TB to others
• Prevent the development of acquired resistance
Fundamental Responsibility and Approach in TB Treatment
• Assure that appropriate regimen is prescribed by MOs
• Ensure successful completion of therapy
(adherence)
• Utilize directly observed therapy (DOT) as standard-of-care
Adherence
•Nonadherence is a major problem in TB control
•Patient education is the most effective tool to prevent default—USE IT!!
•Use case management and directly observed therapy (DOT) to ensure patients complete
treatment
Why Do Patients Default?
• As their condition improves they may feel better and decide they don’t need meds
• They may experience side effects• Forgetfulness/lack of a reminder!• Travel to cattle posts without refills• Difficulty getting to clinic b/c of
work/distance
What is Case Management?
•Assignment of responsibility within clinic tooversee patient monitoring
-bacteriology-DOT-side effects
•Systematic regular review of patient data
•Plans in place to address barriers to adherence BEFORE default occurs
Directly Observed Therapy (DOT)
•Health care worker watches patient swallow each -Dose of medication
-Every pill, every day-Self-administered is NOT DOT
REMEMBER
DOT for all patients on all regimens
NO exceptions
Directly Observed Therapy (DOT)
•DOT can lead to reductions in relapse and acquired drug resistance
•Use DOT with other measures to promote adherence
•DOT is the key to CURE
Factors Guiding Treatment Initiation
• Epidemiologic information– e.g., circulating strains, resistance patterns
• Clinical, pathological, chest x-ray findings
• Microscopic examination of acid-fast bacilli
(AFB) in sputum smears
Basic Principles of Treatment
•Determine the patient’s HIV status- this could save their life!
•Provide safest, most effective therapy in shortest time
•Multiple drugs to which the organisms are susceptible
•Never add single drug to failing regimen
•Ensure adherence to therapy (DOT)
Standard Treatment Regimen
• Initial phase: standard four drug regimens (INH, RIF, PZA, EMB), for 2 months
• Continuation phase: additional 4 months
Treatment of TB for HIV-Negative Persons
•2 months HRZE followed by 4HR
•Four drugs in initial regimen always- Isoniazid (INH)
- Rifampin (RIF)
- Pyrazinamide (PZA)
- Ethambutol (EMB) or streptomycin (SM)
(Streptomycin replaces Ethambutol in TB meningitis)
Treatment of TB for HIV-Positive Persons
•Management of HIV-related TB is complex and patient care needs to be coordinated withIDCC
•HIV-infected patients already on ARVs who develop TB should begin anti-TB meds immediately
•Patients on 1st line ARVs may start Category I ATT.•Patients on ARV regimen with efavirenzshould be reviewed by a specialist.•If patient is on 2nd or 3rd line ARVs discuss with specialist before starting ATT.
• HIV-infected TB patients should be evaluated for ARVs immediately– Pts with CD4<=200 should start ARVs
within two weeks after start of ATT– Pts with CD4s>200 may defer until end of
ATT
Treatment of TB for HIV-Positive Persons
Extrapulmonary TB
•In most cases, treat with same regimens used for pulmonary TB
Bone and Joint TB, Miliary TB, or TB Meningitis in Children
•Treatment extended > 6 months depending on site of disease
•In TB meningitis Streptomycin replaces Ethambutol
ChildrenChildren are at an increased risk for TB
disease• If the disease is severe (meningitis,
military TB, etc.) use Category I treatment, SM replaces EMB in small children
• For less severe disease: treat with category III regimen
In most cases, treat with same regimens used for adultsInfants
Treat as soon as diagnosis is suspected
Infants and Children
Dosing of CPT in Children
Age and weight of child
Recommended daily dose
Suspension 5ML syrup =200mg/40mg
Child Tablet 100mg/20mg
Single strength adult tablet 400mg/80mg
Double Strength adult tablet 800mg/160mg
6 weeks to 6 months (<5kg)
100mg sulfamethoxasole/20mg trimethoprim 2.5ml 1 tablet n/a n/a
6 months to 5 years (5-15Kg)
200mg sulfamethoxasole/40mg trimethoprim 5ml 2 tablets 1/2 tablet n/a
6 to post pubertal
400 mg sulfamethoxasole/80mg trimethoprim 10ml 4 tablets 1 tablet 1/2 tablet
Post pubertal and Adults
800 mg sulfamethoxasole/160mg trimethoprim n/a n/a 2 tablets 1 tablet
Multidrug-Resistant TB (MDR TB)
•Presents difficult treatment problems• Lengthy, multi-drug regimen• Side effects common• Management complex
•Treatment must be individualized
•Clinicians unfamiliar with treatment of MDR TB should seek expert consultation
•Always use DOT to ensure adherence
Multidrug-Resistant TB (MDR TB) Con’t
• 6 months intensive treatment (always including an injectable drug) followed by at least an 18 month continuation phase
• Only specialist physicians at the referral hospitals can initiate MDR treatment
Treatment Monitoring
• Sputum smear microscopy for AFB at 2 months and 6 months– If positive at two months, repeat at 3
• If still smear positive at 3 months, continuation phase (4HR) is still started while awaiting DST results
• Continue drug-susceptibility tests if smear-positive after 3 months of treatment
Caused by Adverse Reaction Signs and Symptoms
Any drug Allergy Skin rash
Ethambutol Eye damage Blurred or changed vision
Changed color vision
Isoniazid,
Pyrazinamideor
Rifampin
Hepatitis Abdominal pain
Abnormal liver function test
results
Fatigue
Lack of appetite
Nausea
Vomiting
Yellowish skin or eyes
Dark urine
Adverse Drug Reactions
Adverse Drug Reactions
Caused by Adverse Reaction Signs and Symptoms
Isoniazid Peripheral neuropathy
Tingling sensation in hands and feet
Pyrazinamide Gastrointestinalintolerance
Arthralgia
Arthritis
Upset stomach, vomiting, lack of appetite
Joint aches
Gout (rare)
Streptomycin Ear damage
Kidney damage
Balance problems
Hearing loss
Ringing in the ears
Abnormal kidney function test results
Caused by Adverse Reaction Signs and Symptoms
Rifamycins
• Rifabutin
• Rifapentine
• Rifampin
Thrombocytopenia
Gastrointestinal intolerance
Drug interactions
Easy bruising
Slow blood clotting
Upset stomach
Interferes with certain medications, such as birth control pills, birth control implants, and methadone treatment
Common Adverse Drug Reactions
Drug Interactions
• Relatively few drug interactions substantially change concentrations of antituberculosis drugs
• Antituberculosis drugs sometimes change concentrations of other drugs
-Rifamycins can decrease serum concentrations of many drugs, (e.g., most of the HIV-1 protease inhibitors), to subtherapeutic levels
-Isoniazid increases concentrations of some drugs (e.g., phenytoin) to toxic levels