# Presentation: 713689

## Treatment of TB Disease

**This is an archived document.**

## Basic Principles of Treatment

- 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

## Adherence

- Nonadherence is a major problem in TB control
- Use case management and directly observed
-  therapy (DOT) to ensure patients complete treatment

## Case Management

- Assignment of responsibility
- Systematic regular review
- Plans to address barriers to adherence

## Directly Observed Therapy (DOT)

- Health care worker watches patient swallow each
- dose of medication
- Consider DOT for all patients
- DOT should be used with all intermittent regimens
- DOT can lead to reductions in relapse and acquired
- drug resistance
- Use DOT with other measures to promote adherence

## Treatment of TB for HIV-Negative Persons

- Include four drugs in initial regimen
-  Isoniazid (INH)
-  Rifampin (RIF)
-  Pyrazinamide (PZA)
-  Ethambutol (EMB) or streptomycin (SM)
- Adjust regimen when drug susceptibility results are
- known

## Treatment of TB for HIV-Positive Persons

- Management of HIV-related TB is complex
- Care for HIV-related TB should be provided
- by or in consultation with experts in management
- of both HIV and TB

## Treatment of TB for 

- HIV-Positive Persons (cont.)

- RIF-based regimens generally recommended for persons
- Who have not started antiretroviral therapy
- For whom PIs or NNRTIs are not recommended

- Initial treatment phase should consist of
- Isoniazid (INH)
- Rifampin (RIF)
- Pyrazinzamide (PZA)
- Ethambutol (EMB)

- RIF may be used with some Pls and NNRTIs

## Treatment of TB for 

- HIV-Positive Persons (cont.)

- For patients receiving PIs or NNRTIs,** **initial treatment
- phase may consist of
-  Isoniazid (INH)
** **Rifabutin (RFB)
-  Pyrazinamide (PZA)
-  Ethambutol (EMB)
- An alternative nonrifamycin regimen includes INH,
- EMB, PZA, and streptomycin (SM)

## Extrapulmonary TB

- In most cases, treat with same regimens
- used for pulmonary TB

- Bone and Joint TB, Miliary TB,
- or TB Meningitis in Children

- Treat for a minimum of 12 months

## Pregnant women 

- 9-month regimen of INH, RIF, and EMB
- PZA and SM are contraindicated
- PZA not contraindicated in HIV-positive pregnant
-      women

- In most cases, treat with same regimens used for
-      adults

**  **
- Treat as soon as diagnosis suspected

- Children

- Infants

## Treatment Regimens for TB 

- Resistant Only to INH

- HIV-Negative Persons
- Carefully supervise and manage treatment to avoid
- 	development of MDR TB
- Discontinue INH and continue RIF, PZA, and EMB
- 	or SM for the entire 6 months
- Or, treat with RIF and EMB for 12 months
- HIV-Positive Persons
- Regimen should consist of a rifamycin, PZA, and EMB

## Multidrug-Resistant TB (MDR TB)

- Presents difficult treatment problems
- Treatment must be individualized
- Clinicians unfamiliar with treatment of MDR TB should
- seek expert consultation
- Always use DOT to ensure adherence

## Monitoring for Adverse Reactions

- Baseline measurements
- Monitor patients at least monthly
- Monitoring for adverse reactions must be
- individualized
- Instruct patients to immediately report adverse
- reactions

## Monitoring Response to Treatment

- Monitor patients bacteriologically monthly until
- cultures convert to negative
- After 3 months of therapy, if cultures are positive
- or symptoms do not resolve, reevaluate for
-  Potential drug-resistant disease
-  Nonadherence to drug regimen
- If cultures do not convert to negative despite 3
- months of therapy, consider initiating DOT