unit 8: complications and special situations botswana national tuberculosis programme manual...
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Unit 8: Complications and Unit 8: Complications and Special SituationsSpecial Situations
Botswana National Tuberculosis Programme Manual Training for Medical Officers
Slide 8-2Unit 8: Complications and Special Situations
ObjectivesObjectives
At the end of this unit, participants will be able to:
• Manage Category I, II, and second-line therapy in special situations:
• Peripheral neuropathy
• Psychiatric illness and MDR
• Paradoxical reactions
• Pregnancy• Breastfeeding• Rash• Liver disease• Kidney Disease
Slide 8-3Unit 8: Complications and Special Situations
PregnancyPregnancy
• Every woman of child bearing age should be asked if she is pregnant prior to starting anti-TB treatment
• Successful outcome of pregnancy largely depends on successful completion of anti-TB treatment
• Category I- drugs are safe in pregnancy
• Category II- Streptomycin should be avoided if possible as it can cause ototoxicity of the foetus
Slide 8-4Unit 8: Complications and Special Situations
Pregnancy: Category IVPregnancy: Category IV
If a woman is pregnant, if possible:
• Avoid the first trimester and start treatment during the 2nd or 3rd trimester
• Avoid amikacin (and streptomycin) until after delivery (fetal ototoxicity possible)
• Avoid ethionamide (teratogenic in animals)
Slide 8-5Unit 8: Complications and Special Situations
BreastfeedingBreastfeeding
• Women on Category I and II Regimens should continue breastfeeding
• If mother has smear+ TB and baby does not have active TB, give baby INH, as appropriate for weight, for 6 months followed by BCG vaccination
Courtesy of: Jeanne Raisler
Slide 8-6Unit 8: Complications and Special Situations
Rash in TB Treatment (1)Rash in TB Treatment (1)
• Before attributing a skin symptom or rash to TB medications, assess• Was it present before TB therapy began?• Is it a condition unrelated to TB treatment?
• Many persons on TB treatment also have HIV• Many people with HIV have skin conditions• ARVs can also cause skin conditions, especially
NVP
Slide 8-7Unit 8: Complications and Special Situations
Rash in TB Treatment (2)Rash in TB Treatment (2)
• Mild to Moderate rashes• Skin rash with mild itching• No blisters or mucous membrane involvement
• Management• Consider other causes (scabies, etc.)• Aqueous cream, Calamine skin lotion• May need to stop TB medications• Chlorpheniramine 4 mg tds, or• Promethazine 25-50 mg nocte
Slide 8-8Unit 8: Complications and Special Situations
Mild to Moderate RashMild to Moderate Rash
Source: I-TECH, 2006.
Mild Rash
Slide 8-9Unit 8: Complications and Special Situations
Severe RashSevere Rash
Rash with:
• Persistent itchiness
• Mucous membrane involvement and/or
• Blistering
• Urticaria (hives)
Slide 8-10Unit 8: Complications and Special Situations
Severe RashSevere Rash
Source: I-TECH, 2006.
Slide 8-11Unit 8: Complications and Special Situations
Severe Rash Management (1)Severe Rash Management (1)
• Stop all TB drugs together
• Hospitalise the patient
• Give IV fluids as required
• Consider antibiotics for severe desquamation/exfoliation
• Treat like a burn
• Consider the use of steroids
Slide 8-12Unit 8: Complications and Special Situations
Severe Rash Management (2)Severe Rash Management (2)
• Most patients can wait for the rash to resolve before resuming TB treatment
• If the patient has life-threatening TB as well as life-threatening rash, may provide at least 2 TB drugs (3 drugs preferred) the patient has not taken before until the rash subsides
Slide 8-13Unit 8: Complications and Special Situations
Treatment After Rash (1)Treatment After Rash (1)
If it is not obvious which caused the reaction, which is often the case, re-introduce TB medications in a step-wise fashion• Gradually increase the dose of each medication • If no reaction, continue the medication and
gradually increase the dose of the next medication• Use in reverse order of likelihood of cause of rash
Slide 8-14Unit 8: Complications and Special Situations
Schedule for Schedule for Reintroduction of Anti-TB DrugsReintroduction of Anti-TB Drugs
Day Drug and dose
1 INH 25 mg
2 INH 50 mg
3 INH 100 mg
4 INH 200 mg
5 INH 300 mg*
6 INH 300 mg + R 150 mg
7 INH 300 mg + R 300 mg
8 INH 300 mg + R 450 mg
9 INH 300 mg + R 600 mg*
10 INH 300 mg + R 600 mg + E 400 mg
11 INH 300 mg + R 600 mg + E 800 mg
12 INH 300 mg + R 600 mg + E 1200 mg*
13 INH 300 mg + R 600 mg + E 1200 mg + Z 500 mg
14 INH 300 mg + R 600 mg + E 1200 mg + Z 1000 mg
15 INH 300 mg + R 600 mg + E 1200 mg + Z 1500 mg
16 INH 300 mg + R 600 mg + E 1200 mg + Z 2000 mg*
Slide 8-15Unit 8: Complications and Special Situations
Treatment After Rash (2)Treatment After Rash (2)
• If gradual reintroduction succeeds without a recurrence of rash, can continue treatment
• If the offending drug causes a reaction, suspend it and replace the offending drug with another agent
• May leave out pyrazinamide, ethambutol or streptomycin
• Get expert advice; substitutions may require longer duration of therapy
Slide 8-16Unit 8: Complications and Special Situations
Liver DiseaseLiver Disease
• Three important issues complicate therapy:• Hepatotoxicity of anti-TB drugs• Acute liver disease with concurrent TB• Chronic liver disease with concurrent TB
• Provided there is no clinical evidence of chronic liver disease, ATT is safe in patients with hepatitis virus carriage, history of acute hepatitis or excessive alcohol consumption
Slide 8-17Unit 8: Complications and Special Situations
Acute Hepatitis Acute Hepatitis Prior to TB TreatmentPrior to TB Treatment
• Evaluate the cause:• Viral (Hepatitis A, Hepatitis B)• Alcohol• ARVs• Traditional medicines• Other toxins
• If possible, await resolution of acute hepatitis before starting TB treatment
Slide 8-18Unit 8: Complications and Special Situations
Acute HepatitisAcute HepatitisPrior to TB Treatment (2)Prior to TB Treatment (2)• Consult TB expert
• Initial phase: SE for 3 months• Continuation phase:
• RH for 6 months OR• SE for 9 additional months
• Avoid Z, H, R and Eth (ethionamide) during acute hepatitis
Slide 8-19Unit 8: Complications and Special Situations
Established Chronic Liver Disease Established Chronic Liver Disease Prior to TB TreatmentPrior to TB Treatment• Evaluate the cause
• Viral: Hepatitis B, Hepatitis C• Alcohol• Disseminated TB
• Avoid PZA• Requires close monitoring
• Liver function tests• Sputum samples• Experienced TB doctor
Slide 8-20Unit 8: Complications and Special Situations
TB Treatment with TB Treatment with Chronic Liver DiseaseChronic Liver Disease
• Preferred option• Initial: 2 months RHES• Continuation: 6 months RH
• Second option • Initial: 2 months RES• 10 months RE
• Third option• Initial: 2 months HES• Continuation: 10 months HE
Slide 8-21Unit 8: Complications and Special Situations
HepatotoxicityHepatotoxicity
• Symptoms: Fever, malaise, right upper quadrant abdominal pain, nausea, vomiting, loss of appetite
• Signs:• ALT or AST more than 3x increased if symptoms
of hepatitis are present, or more than 5x increased without symptoms
• Bilirubin or alkaline phosphatase more than 2x increased
• Jaundice
Slide 8-22Unit 8: Complications and Special Situations
TB Drugs & HepatotoxicityTB Drugs & Hepatotoxicity
Hepatotoxic• Pyrazinamide and isoniazid
are the most common causes
• Pyrazinamide causes the most severe
• Rifampicin hepatotoxicity is less common and less severe
• Ethionamide
NOT Hepatotoxic• Ethambutol • Streptomycin
Slide 8-23Unit 8: Complications and Special Situations
HepatotoxicityHepatotoxicity
• Try to rule out other causes of acute liver disease before attributing it to the TB treatment
• In hepatotoxicity, stop all TB drugs until the patient improves
• In case of severe TB, consider using “liver sparing regimen” (Ethambutol, streptomycin, and Ciprofloxacin)
• Admit patients to the hospital if unable to maintain hydration or if hepatic failure develops
Slide 8-24Unit 8: Complications and Special Situations
Acute Hepatitis: Acute Hepatitis: During TB TreatmentDuring TB Treatment
• Rare
• Decision whether to stop or continue anti-TB treatment requires good clinical judgment
• Safest option in acute hepatitis not due to TB is to give streptomycin and ethambutol until the hepatitis has resolved (for a maximum of 3 months) followed by a continuation phase of INH and rifampicin for 6 months
Slide 8-25Unit 8: Complications and Special Situations
Treatment After Hepatotoxicity (1)Treatment After Hepatotoxicity (1)
• When hepatitis has resolved, reintroduce therapy
• If lab tests are not available, wait until 2 weeks after the jaundice ends
• If lab tests are available wait until AST/ALT < 2x normal• Stepwise fashion, starting with safest drugs• Try to create a safe combination regimen
Slide 8-26Unit 8: Complications and Special Situations
Reintroduction of Reintroduction of Drugs After HepatoxicityDrugs After Hepatoxicity
• Continue EMB, streptomycin, +/- ciprofloxacin• INH 300 mg daily x 4 days• If no symptoms, add
• Rifampicin 600 mg daily x 4 days
• If no symptoms, 2 options:• Do not try PZA • Try PZA
• D/C streptomycin and ciprofloxacin when back on E, H, R
Slide 8-27Unit 8: Complications and Special Situations
Treatment After Hepatotoxicity (2)Treatment After Hepatotoxicity (2)
• Pyrazinamide toxicity• 2 months RHES then 6 months RH • Check sputum at 2, 5, and 7 months
• Pyrazinamide and isoniazid toxicity• 2 months RES then 10 months RE• Check sputum at 2, 5, 8, and 11 months
• Pyrazinamide and rifampicin toxicity• 2 months HES then 10 months HE• Check sputum at 2, 5, 8, and 11 months
Slide 8-28Unit 8: Complications and Special Situations
Renal DiseaseRenal Disease
• Some patients with active TB will have renal disease due to either TB in the urinary tract or another condition
• Adjust dose of ethambutol based on creatinine clearance if renal disease is suspected
• Avoid streptomycin unless specialist care is available
• Safest regimen: 2HRZ/4HR
Slide 8-29Unit 8: Complications and Special Situations
Key PointsKey Points
• Careful assessment is needed to distinguish drug reactions from other conditions
• Successful management of adverse drug reactions is necessary for patient health and integrity of the TB control program
• Treatment of patients with chronic liver or kidney disease may require changes in regimen or dosing
• Issues with category II regimen and second-line treatment are more complex