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T.B. Special Situations

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  • 1. PROF. DR. ZAFAR HUSSAIN IQBAL MBBS, DTCD, MRCP, FRCP PROF. OF PULMONOLOGY AIMC / JHL Management of Tuberculosis In Special Situations

2. Tuberculosis - Global TB is shadow of poverty 1/3rd of the world population infected (1.7 billion) 10% gets the disease 10 million new cases each year 4 million deaths each year Crash of Boeing 747 each hour every day 1 untreated pt. infects 10-15 persons per year WHO declared TB as global emergency 1993 3. Tuberculosis - Pakistan Ranks 8th amongst 22 high burden countries Incidence 181 /100,000 Est. no of new TB cases 297,108 New sputum smear +ve 81 /100,000 Prevalence 329 /100,000 Mortality 40 /100,000 New MDR Tb cases 3.2 % (WHO Global TB Report Published in 2009 Data of 2007) 4. Tuberculosis - Diagnosis Pulmonary TB Direct sputum smear microscopy - Gold Standard CXR unreliable, helpful in smear negative cases Tuberculin testing limited value in clinical work ESR no diagnostic value Serological tests PCR Extra-Pulmonary TB Tissue smear for AFB and AFB culture Histology Clinical setting 5. Tuberculosis Treatment New case Smear positive pulmonary TB Smear negative pulmonary TB Extra-pulmonary TB Initial intensive phase 2 RHEZ Continuation phase 6 RH or 6 HE Re-treatment Relapses Treatment failure Defaulter Initial phase 2 RHEZ + S, 1 RHEZ Continuation phase 5 RHE 6. Pregnancy H, R, PZA, E : Safe, No evidence of teratogenecity or congenital malformations Add Pyridoxine with INH to avoid small risk of CNS damage in infants Rifampicin : High dose teratogenic in animals Streptomycin : Ototoxic, may cause deafness in babies, Contraindicated Capreomycin, Kenamycin, Viomycin Ethionamide & Prothionamide : Teratogenic 7. Infants of T.B. mothers & Breast Feeding Mothers must continue A.T.T during feeding Child should not be separated Mother should cover her mouth during cough particularly if smear +ve INH prophylaxis : 5 mg/Kg 2 months Do T.T - if ve, stop INH, give BCG - if +ve, continue INH 4 months, then BCG Do not give BCG while on INH INH resistant BCG Rifampicin + INH 3 months 8. Women on O.C.P Rifampicin: Hepatic enzyme inducer O.C.P may become ineffective Rifampicin babies Extra / alternative protection required Higher dosage 9. Renal Impairment - CKD Acquired Immunodeficiency state - High risk of T.B. 50% Tuberculin -ve Common in Asian and African origin in UK Three categories CKD Dialysis Transplant General principle - Standard chemotherapy, standard duration, Dose interval modification Creatinine clearance is a better indicator than serum creatinine 10. Grades Of Renal Impairment In CKD Stage 1 CKD : Normal CC with structural abnormality Stage 2 CKD : CC 60 90ml/ min Stage 3 CKD : CC 30 60ml/min Stage 4 CKD : CC 15 30ml/min Stage 5 CKD : CC < 15ml/min with or without dialysis 11. Renal Impairment Rifampicin: Safe , Active metabolite excreted in bile. Inactive metabolite (10%) excreted in urine Use normal dose in all stages INH Safe, Metabolized in liver . Add pyridoxine to avoid P.N. Use normal dose in all stages 12. Renal Impairment Pyrazinamide Metabolized in liver Delayed elimination of drug & metabolites in CKD 4 & 5 Needs dose interval adjustment CKD 1-3 < 50kg : 1.5g daily > 50Kg : 2 g daily CKD 4-5 25-30 mg/Kg 3 x / week 13. Renal Impairment Ethambutol Nephrotoxic , Renal excretion - 80% unchanged Ocular toxicity dose dependent Serum monitoring required should be 35 years Female sex Oriental race (EAST ASIAN) Pre-existing liver disease Extensive tuberculosis High alcohol consumption Malnutrition and hypo Albuminemia Other hepatotoxic drugs Slow Acetylator status High dosage in relation to body weight 22. Management Recommendation Of Joint TB Committee Of BTS ALT/AST (< Twice normal) - Continue ATT - Check after 2 weeks ALT/AST (>Twice normal) - Continue ATT - Check LFTs weekly for 2 weeks - Then every 2 weeks until normal ALT/AST (>Thrice normal) + Symptoms - Anorexia, Nausea, Vomiting, Abdominal Pain , Jaundice - STOPATT 23. Recommendation Of Joint TB Committee Of BTS AST/ALT (>5 time normal) OR Bilirubin Even If Patient Asymptomatic Stop ATT If patient is smear ve / Clinically stable - Wait until LFTs are normal - No need for alternate drugs If patient is smear +ve / Clinically unstable - Start Ethambutol, Streptomycin and one of the reserve drugs until LFTs are normal - Continue safe drugs until LFTs are normal 24. Recommendation Of Joint TB Committee When LFTs are normal Reintroduce ATT to detect offending drugs Start with least hepatotoxic one by one INH > RIF > PZA If no reaction Continue ATT Stop alternate drugs If reaction has developed Stop offending drug Continue remaining drugs Ensure adequate regimen and duration 25. HIV - Infected or AIDS Standard regimen usually good response Drug reactions more common Thiacetazone should be avoided Prolonged treatment Patients on Anti-retroviral therapy- high risk of interaction with Rifampicin withhold ATT during this period 26. SILICOSIS More prone to develop P.T.B Difficult to treat - Impaired macrophages function Poor penetration of drug in P.M.F Hong Kong study rock islands of Granite 40% suffer from P.T.B High relapse rate 22 to 33% : 2 & 5 years Slower sputum conversion Standard regimen, longer duration 27. THANK YOU

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