PTB Management of Drug – Induced Hepatotoxicity

- ALT – requested for evidence of hepatotoxicity and monitoring of patients

New case – never had treatment or taken TB drugs for <1 month with baseline risk factors for hepatotoxicity or abnormal baseline LFTs (2-4
Retreatment – previous treatment for at least 1 month weeks after the start of tx)
Monoresistant – one 1st line - all medications should be stopped when the serum ALT >3x ULN +
Polyresistant - >1 1st line aside from both R and I symptoms or 5x ULN w/o symptoms
MDR – both R and I - wait for 2 weeks after resolution of jaundice
XDR – fluoroquinolones and at least 3 2nd line injectable drugs - ALT becomes <2x ULN – stepwise reintroduction of rifampicin +/-
Fluoroquinolones – sputum sensitizer hence may cause sputum ethambutol followed by INH after 3-7days
(-) on DSSM - permanently d/c pyrazinamide
- Compensated liver cirrhosis 2HRES/6HR; 2HSE/10HE or 9HRE
TST – 10mm induration is (+) - Acute Hepatitis – 3SE/6HR is the safest option, if hepatitis not resolved
then give 12SE
15 and above:
Cpugh for more than 2 weeks, unintentional wt loss, fever, hemoptysis, Management of TB among patients with renal dysfunction
chest/back pain, easy fatiguability, night sweats, shortness of breath -give HRZE 2x a week and HR for the rest of the week for the intensive
phase followed by 4HR
Massive hemoptysis 200-600cc/day – only contraindication for DSSM -For patients on hemodialysis – give tx after hemodialysis session.
Collect 1tsp for DSSM and not less than 1cc for geneXpert -For patients on peritoneal dialysis, antiTB medications may be
administered regardless of PD schedule; begin with doses similar to those
Treatment after Failure recommended for patients on hemodialysis.
> sputum (+) at 5mos or late during treatment
> clinically dx – does not show clinical improvement anytime during the Management of Cutaneous Adverse Reactions
treatment -d/c then restart medications at full dose or reintroduce 1 by 1 at intervals
of 3-7days when cutaneous reaction has improved
Treatment after Lost to FFup – lost to ffup for >/= 2mos
*Serum uric acid should only be requested for patients who develop
Cat 1 – New except CNS and bones – 2HRZE 4 HR symptoms of gouty arthritis
Cat 1a – New CNS and Bones – 2HRZE 10HR
Cat 2 – Previous tx, relapse, TAF, TALF, PTOU except CNS and Bones – Use of corticosteroids in TB
2HRZES-1HRZE-5HRE In TB meningitis - dexamethasone 0.4 mg/kg/24H with a reducing course
Cat2a – previous tx, relapse, TAF, TALF, PTOU CNS and Bones – 2HRZES- over 6-8 weeks
1HRZE-9HRE In TB pericarditis - prednisolone 60 mg for the first 4 weeks, 30 mg for
weeks 5-8, 15 mg for weeks 9-10 and 5 mg for week 11
CAT 1 2 HRZE 4HR
30-37kg 2tabs 2tabs Pregnant with TB
38-54kg 3tabs 3tabs -all are safe except streptomycin
55-70kg 4tabs 4tabs -give supplemental pyridoxine 25mg/day
>70kg 5tabs 5tabs
Lactating with TB
CAT 2 2HRZE+S(1mg/2ml) 1HRZE 5HRE -feed infant before taking medications as drugs will be found in breastmilk
in concentration equal to a small fraction of the therapeutic dose used in
30-37kg 2tabs + 1mg 2tabs 2tabs
infants
38-54kg 3tabs + 1mg 3tabs 3tabs
55-70kg 4tabs + 1mg 4tabs 4tabs
Taking OCPs with TB
>70kg 5tabs + 1mg 5tabs 5tabs -Rifampicin decreases efficacy
-take OCP in higher concentration of estrogen
Dose Max dose -use another form of contraception
H 5mg/kg 400mg/day
R 10mg/kg 600mg/day HIV with TB
Z 25mg/kg 2g/day -Antiretroviral therapy should be initiated after the second week of TB
E 15mg/kg 1.2g/day treatment regardless of CD4 count
S 15mg/kg 1g/day -For patients with TB meningitis, antiretroviral therapy should be initiated
after the intensive phase of TB treatment.
Ffup DSSM -Efavirenz is the preferred NNRTI for HIV patients on TB treatment. Avoid
Cat 1 – 2nd, 5th and 6th the use of nevirapine because of drug-drug interactions
*if positive on the 2nd, ffup on the 3rd. If still (+), refer to PMDT -Co-trimoxazole prophylaxis at a total daily dose of 800 mg
*if positive on the 5th – treatment failed – refer to DOTS sulfamethoxazole + 160 mg trimethoprim should also be given to prevent
Cat 2 – 3rd, 5th, 8th (refer to PMDT if (+) on 3rd) Pneumocystis jirovecii pneumonia regardless of CD4 count

Non-infectious: Latest TB Infection – INH 300mg for 6mos under DOTS

Smear (+) – 14days after start of tx Sputum induction (15-20 minutes of nebulization with 15mL 2.5-5%
Clinically dx – 5days after apt and adequate therapy hypertonic saline)