TREATING TB IN

ADULTS
Meenakshianandi A/P Krishnan
REFERENCE
CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF TB (3
RD

EDITION),2012.
Aim of TB treatment should be both cure and reduce risk of
transmission. TB is an airborne infectious disease. The risk of TB
infection post-exposure is further determined by a few factors:-
Infectiousness of the index case
Nature and duration of the contact
Immune status of the contact
Heath education must be given to the patient and family members/carers
at the time of starting treatment. This should include:-
a. nature of the disease
b. necessity of strict adherence with the prolonged treatment
c. risks of defaulting treatment
d. side effects of medication
e. risks of transmission and need for respiratory hygiene as well as
cough/sneeze etiquette
Treating new cases
Presently, six-month regimen consisting of 2 months of daily EHRZ*
(2EHRZ) followed by 4 months of daily HR* (4HR) is recommended for
newly-diagnosed PTB1, level III based on many years of well-designed
randomised controlled trial (RCT).
6 month regimen=2 EHRZ+4HR
Dosages of first line antiTB drugs
Previously treated TB patients include those patients treated as new
cases who have taken treatment for more than one month and are
currently smear or culture positive again (i.e. failure, relapse or return
after default).
When there is interruption in treatment, the treating doctor needs to
ascertain reason and duration of the interruption and then decide
whether to restart the entire course, to continue from the last dose or to
stop the treatment.

Interruption in intensive phase
Interruption in maintenance phase

Optimal Duration of Treatment
Current evidence suggests that the optimal duration of treatment for
sputum positive PTB is at least six months.
Regimens with shorter duration of rifampicin are associated with higher
risk of failure, relapse and acquired drug resistance.
Patients with sputum positive pulmonary tuberculosis should receive
antituberculous drugs for a minimum duration of six months.
Fixed-Dose Combinations (FDCs)
The following FDC preparations are registered in Malaysia:-
Forecox-Trac Film Coated Tab: Isoniazid, Rifampicin, Ethambutol and Pyrazinamide
Rimactazid 300 Sugar Coated Tab: Isoniazid and Rifampicin
Rimcure 3-FDC Film Coated Tab: Isoniazid, Rifampicin and Pyrazinamide
Akurit-Z Tab: Isoniazid, Rifampin (Rifampicin) and Pyrazinamide
Akurit Tab :Isoniazid and Rifampin (Rifampicin)
Akurit-Z Kid Dispersible Tab: Isoniazid, Rifampin (Rifampicin) and Pyrazinamide
Akurit-4: Ethambutol, Isoniazid, Rifampin (Rifampicin) and Pyrazinamide
The two FDCs available in MoH Drug Formulary for adults are:-
a. 4-Drug combination: Isoniazid 75 mg, Rifampicin 150 mg, Pyrazinamide 400
mg and Ethambutol 275 mg tablet
b. 3-Drug combination: Isoniazid 75 mg, Rifampicin 150 mg and Pyrazinamide
400 mg tablet

The recommended dosages for the two FDCs are:-
30 - 37 kg body weight: 2 tablets daily
38 - 54 kg body weight: 3 tablets daily
55 - 70 kg body weight: 4 tablets daily
More than 70 kg body weight: 5 tablets daily
Fixed-Dose Combinations (FDCs) are preferred to
separate-drugs combination for the treatment of
tuberculosis.
In patients who develop toxicity, intolerance or
contraindication to specific component drugs, FDCs
can be substituted with separate-drug regimens.
Directly Observed Therapy (DOT)
This strategy combines drug treatment with political commitment, sputum smear
microscopy for diagnosis and directly observed therapy (DOT) to ensure
adherence and good management practice.
The practice of DOT in Malaysia was reported to be 97% (ranging from 93% to
100%)
Direct observation of drug ingestion of the DOTS component should not be the
sole emphasis in TB control programmes. It should not be a blanket approach;
instead it should be a process of negotiation and support, incorporating patients
characteristics and choices.
Besides DOT, other proven good management practices include defaulter tracing
and contact tracing.
Late tracer system or defaulter action, including reminder letters to or home visits
by healthcare worker have been shown to reduce the number of patients who fail
to complete treatment.
Enhanced DOTS involving intensive contact tracing and treating the contacts with
tuberculosis can reduce incidence of TB within a community.
Staff and patient education is also important in improving compliance and success
of antiTB treatment.
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