PowerPoint presentation on basic concepts in treatment of Pulmonary Tuberculosis. By Dr.Tinku Joseph

1. BASIC CONCEPTS IN TREATMENT
OF TUBERCULOSIS
DR. TINKU JOSEPH
DM Resident
Dept of pulmonary medicine
AIMS, Kochi.
Email-: tinkujoseph2010@gmail.com

2. TREATMENT OF TUBERCULOSIS
 TB remains the primary
cause of death due to
infectious disease.
 Periods of treatment
(minimum 6 months)
 Drugs are divided into two
groups
 First line
 Second line

3. LANDMARKS IN CHEMOTHERAPY
 1944: Streptomycin
 1946: PAS
 1952: INH
 1955: Pyrazinamide
 1958: Ethambutol
 1962: Rifampicin
 1956:
Domiciliary treatment
 1964:
Intermittent regimen
 1985:
Short course regimens

4. FIRST LINE DRUGS
 Isoniazide: INH: H: 5 mg/kg
 Rifampicin: RMP: R: 10 mg/kg
 Ethambutol: EMB: E: 15-25 mg/kg
 Pyrazinamide: PZA: Z: 25-35 mg/kg
 Streptomycin: SM: S: 15-20 mg/kg
Remember “ IRESP ”

5. SECOND LINE DRUGS
 Quinolones: 10-15 mg/ kg
Ciprofloxacin: Ci
Ofloxacin: O
Levofloxacin: L
Moxifloxacin: Mo
 Thioamides: 10-15 mg / kg
Ethionamide: Et
Prothionamide: Pt
 Cycloserine: Cy: 10-15 mg/ kg

6. SECOND LINE DRUGS
 Aminoglycosides: 10-15 mg/ kg
Kanamycin: K
Amikacin: Ami
Capreomycin: Cap
 Para amino salicylic acid: PAS: 150 mg/kg
 Thiacetazone: T: 3mg/kg
 Clofazimine

7. THIRD LINE DRUGS
 Rifamycin derivatives: Rifabutin, Rifapentin
 Amoxycillin + clavulinic acid
 Linezolide
 High dose INH

8. New WHO Classification
 Group 1:Isoniazid,Rifampicin,Ethambutol,Pyrizinamide
 Group2:Injectables: Streptomycin, Kanamycin, Amikacin
 Group 3 : Quinolones like Levofloxacin, Moxifloxacin
 Group 4 : Other bacteriostatic second line drugs like
Ethionamide, Prothionamide, Cycloserine, PAS
 Group 5 : Agents with unclear role like Linezolide,
Amox-Clav, Imp-cilastin High dose INH

9. A REGIMEN
 Specific combination of drugs prescribed in
specific doses, specific rhythm and for a specific
time duration is defined as a regimen.

10. PECULARITIES OF AN
ANTI-TB REGIMEN
 More than one drugs are used. Always a combination
chemotherapy.
 Both bactericidal and bacteriostatic drugs are used
together.
 There is a an intensive and a continuation phase
 The drugs are given on daily or alternate basis
regardless of the half life of the drug.
 The treatment is prolonged.

11. COMBINATION CHEMOTHERAPY
 Monotherapy shown to cause failure.
 Natural resistant mutants in a bacterial population:
1 per 1 lakh: resistant to SM
1 per 10 lakhs: resistant to INH etc
 Addition of bacteriostatic drugs prevents occurrence of
drug resistant mutants

12. PROLONGED THERAPY
 Subgroups of bacteria are:
1)Rapid multipliers
2)Intracellular dormants (Intermittent growers)
3)Extracellular dormants (Intermittent growers)
4)Persisters (Occasional growers)
 Bacterial population reduces to less than 5%
within 2 months.
 Bactericidal drugs act only when the bacteria is
actively multiplying

13. LAG PHASE CONCEPT

14. ANTI-TB REGIMENS
 Standard regimens: 18 months
2SHP/16HP
2SHT/16HT
2(SHT)3/16(HT)3
 Intermediate regimens: 9-12 months duration
2SHRE/10HE
2HREZ/10HE
2HRE/7HR
2SHRZE/7HE

15. ANTI-TB REGIMENS
 Short course regimen: 6 months
2HREZ/4HR
2HREZ/ 4HRE
2(HREZ)3/4(HR)3
2(SHREZ)3/1(HREZ)3/5(HRE)3
2(HRZ)3/4(HR)3
 Ultra short course regimen: 4 months
4HREZ
4SHRZ

16. STEPS IN STARTING TREATMENT
1. Confirm the diagnosis
2. Disclose the diagnosis to the patient
3. Do thorough counseling of patient and relatives
4. Categorize the patient
5. Start proven regimen in correct dosages and
rhythm and give for recommended duration
6. Avoid un-necessary co-prescriptions
7. Monitor closely

17. Confirm the diagnosis

18. Disclose the diagnosis

19. Do thorough counseling

20. Insist on following
 Resolution of symptoms does not mean cure and
persistence of symptoms not necessarily mean
treatment failure
 Treatment default is dangerous and should be
always avoided. No reason is acceptable. Explain
the end result of default
 Tb is curable
 It is our social duty not to spit on roads and to
cover mouth while coughing !!

21. CATEGORIZE THE PATIENT
 New smear positive pulmonary case OR seriously
ill pulmonary/ extra-pulmonary case: (CAT - 1)
Start 2HREZ/4HR
 New smear negative pulmonary case OR non-serious
extra-pulmonary case:
Start 2HRZ/4HR
 Relapse, failure & default case of TB: (CAT - 2)
Start 2SHREZ/1HREZ/5HRE

22. Indications to start 2nd line drugs
 Resistance to 1st line drugs
 Failure of clinical response
 There is contraindication for 1st line drugs.
 Patient is not tolerating 1st line drugs.

23. CO-PRESCRIPTIONS
 Antacids/ H2 blockers/ PPI
 Milk and eggs
 Vitamin B6
 Multi-vitamins
 Corticosteroids
 Immunotherapy
 Anabolic steroids ??

24. ASSESS FREQUENTLY
 After 1 week: for adverse drug effects
 After 1 month: symptoms, X-ray, sputum
 At the end of intensive phase (2 months):
symptoms, X-ray, sputum
 At the end of extended intensive phase:
symptoms, X-ray, sputum
 At end of 3 months: eye check up
 SOS: LFT, RFT
 Sputum ZN stain/ culture positivity indicates
treatment failure