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53 Cards in this Set
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- Back
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First-line Initial Phase TB treatment
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INH + RIF + PZA + EMB
(isoniazid + rifampin + pyrazinamide + ethambutol) BEST: 7 days a week for 8 weeks OR 5 days a week for 8 weeks Next Best: 7 days a week for 2 weeks, then twice a week for 6 weeks OR 5 days a week for 2 weeks then twice a week for 6 weeks OR 3 times a week for 8 weeks |
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Recommended duration of TB treatment
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26 weeks
(initial phase + continuation phase) initial is usually 8 weeks continuation is usually 18 weeks There is a 39 week regimen (4th choice) using only INH+RIF+EMB (if PZA cannot be given) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + PZA + EMB 7 days a week for 8 weeks |
Regimen 1 (PREFERRED)
Best Continuation Phase: INH + RIF (7 days/wk for 18 weeks) OR INH + RIF (5 days/wk for 18 weeks, DOT only) OR INH + RIF (2 days/wk for 18 weeks) Next Best (only for HIV-negative pts with negative sputum cultures & radiographs at the end of initial phase): INH + Rifapentine/RPT (1 day/wk for 18 weeks) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + PZA + EMB 5 days a week for 8 weeks |
Regimen 1 DOT-only (PREFERRED)
Best Continuation Phase: INH + RIF (7 days/wk for 18 weeks) OR INH + RIF (5 days/wk for 18 weeks, DOT only) OR INH + RIF (2 days/wk for 18 weeks) Next Best (only for HIV-negative pts with negative sputum cultures & radiographs at the end of initial phase): INH + Rifapentine/RPT (1 day/wk for 18 weeks) |
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How preferred is this Initial Phase, and what should the continuation phase be IF THE PT HAS POSITIVE CULTURES & POSITIVE RADIOGRAPHS at the end of 2 months?
initial: INH + RIF + PZA + EMB 5 days a week for 8 weeks |
Regimen 1 DOT-only (Preferred initial phase)
Continuation phase: INH + RIF (1 day/wk for 31 weeks = 7 months) OR INH + RIF (2 days/wk for 31 weeks = 7 months) |
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continuation phase be IF THE PT HAS POSITIVE CULTURES & POSITIVE RADIOGRAPHS at the end of 2 months?
initial: INH + RIF + PZA + EMB 7 days a week for 8 weeks |
Regimen 1 (Preferred initial phase)
Continuation phase: INH + RIF (1 day/wk for 31 weeks = 7 months) OR INH + RIF (2 days/wk for 31 weeks = 7 months) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + PZA + EMB 7 days/wk for 2 weeks, then 2 days/wk for 6 weeks |
Regimen 2 (Acceptable alternative to Regimen 1)
Best Continuation phase: INH + RIF (2 days/wk for 18 weeks) Next best Continuation phase ONLY FOR PT'S WITH NEGATIVE SPUTUM CULTURES & RADIOGRAPHS AT THE END OF 2 MONTHS/INITIAL PHASE: INH + Rifapentine/RPT (1 day/wk for 18 weeks) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + PZA + EMB 5 days/wk for 2 weeks, then 2 days/wk for 6 weeks |
Regimen 2 DOT-only (Acceptable alternative to Regimen 1)
Best Continuation phase: INH + RIF (2 days/wk for 18 weeks) Next best Continuation phase ONLY FOR PT'S WITH NEGATIVE SPUTUM CULTURES & RADIOGRAPHS AT THE END OF 2 MONTHS/INITIAL PHASE: INH + Rifapentine/RPT (1 day/wk for 18 weeks) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + PZA + EMB 3 days/wk for 8 weeks |
Regimen 3 (Acceptable alternative to Regimens 1 & 2)
Continuation phase: INH + RIF (3 days/wk for 18 weeks) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + EMB 7 days/wk for 8 weeks |
Regimen 4 (ONLY use if PZA cannot be given)
39 weeks of treatment total! Continuation phase: INH + RIF (7 days/wk for 31 weeks) OR INH + RIF (5 days/wk for 31 weeks, DOT only!) OR INH + RIF (2 days/wk for 31 weeks) |
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How preferred is this Initial Phase, and what should the continuation phase be?
initial: INH + RIF + EMB 5 days/wk for 8 weeks |
Regimen 4 DOT required! (ONLY use if PZA cannot be given)
39 weeks of treatment total! Continuation phase: INH + RIF (7 days/wk for 31 weeks) OR INH + RIF (5 days/wk for 31 weeks, DOT only!) OR INH + RIF (2 days/wk for 31 weeks) |
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How many drugs are generally used in Initial Phase TB treatment of previously untreated TB?
Why? |
4 (INH + RIF + PZA + EMB)
4 drugs used because of concerns about INH resistance; this regimen is intended to decrease the secondary development of resistance to RIF in populations resistant to INH. |
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INITIAL PHASE:
If susceptibility results indicate the isolate is sensitive to ________, then _______ can be discontinued. What effect does this have on the treatment duration? |
If susceptible to INH, RIF and PZA,
then EMB can be discontinued overall duration of treatment will not change. |
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If culture-negative TB is suspected (based on symptoms, radiograph, etc.), how long should the course of treatment be?
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4 months total
2 months of INH + RIF + PZA + EMB then 2 months of INH + RIF |
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INH
admin forms? |
tablets
elixir IV/IM solution |
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INH dosing for:
- 1x/week - 2x/week - 3x/week - daily |
INH dosing for:
- 1x/week: 15 mg/kg (900 mg per dose max) - 2x/week: 15 mg/kg (900 mg per dose max) - 3x/week: 15 mg/kg (900 mg per dose max) - daily: 5 mg/kg (300 mg per dose max) |
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RIF dosing for:
- 1x/week - 2x/week - 3x/week - daily |
RIF dosing for:
- 1x/week: NOT DOSED ONCE WEEKLY (RPT instead) - 2x/week: 10 mg/kg (600 mg per dose max) - 3x/week: 10 mg/kg (600 mg per dose max) - daily: 10 mg/kg (600 mg per dose max) |
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RIF
admin forms? |
capsule
IV solution |
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Rifabutin dosing for TB:
- 1x/week - 2x/week - 3x/week - daily |
Rifabutin dosing for:
- 1x/week: NOT DOSED ONCE WEEKLY (RPT instead) - 2x/week: 5 mg/kg (300 mg per dose max) - 3x/week: 5 mg/kg (300 mg per dose max) - daily: 5 mg/kg (300 mg per dose max) |
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Rifabutin:
admin forms? |
capsule
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RPT dosing:
- 1x/week - 2x/week - 3x/week - daily |
Rifapentine dosing for:
- 1x/week: 10 mg/kg (continuation phase, 600mg max) - 2x/week: DOSED ONCE WEEKLY - 3x/week: DOSED ONCE WEEKLY - daily: DOSED ONCE WEEKLY |
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PZA dosing:
- 1x/week - 2x/week - 3x/week - daily |
Pyrazinamide has weight-based dosing:
NOT DOSED ONCE WEEKLY ranges from 1000 - 4000 mg, dependent on weight and 2x/3x/7x per week schedule |
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Rifapentine:
admin forms? |
tablet
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Pyrazinamide:
admin forms? |
tablet
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Ethambutol:
admin forms? |
tablet
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EMB dosing:
- 1x/week - 2x/week - 3x/week - daily |
Ethambutol has weight-based dosing:
NOT DOSED ONCE WEEKLY ranges from 800 - 4000 mg, dependent on weight and 2x/3x/7x per week schedule |
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Tuberculosis pathogen? Classification?
How transmitted? How diagnosed? |
Mycobacterium tuberculosis: aerobic bacillus, does not gram stain but is considered gram+ bacteria
transmitted by aerosolized drops via sneezing, coughing, talking, etc. diagnosed by tuberculin skin test (TST, same as PPD). Also can use sputum smear, culture and PCR. |
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symptoms of active TB
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coughing (may or may not be productive)
fatigue night sweats infiltrates on chest x-ray anorexia, weight loss pleuritic chest pain hemoptysis (coughing up blood) fever |
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treatment regimen for Latent TB
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INH 300 mg daily for 9 months
OR INH 15 mg/kg given 2x/wk OR RIF 600 mg daily for 4 months |
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TB treatment if resistant to INH
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6 months (RIF + PZA + EMB +/- fluoroquinolone)
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TB treatment if resistant to RIF
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12 - 18 months (INH + EMB + fluoroquinolone)
+ PZA for the first 2 months |
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What is MDR-TB, and how do you treat it?
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MDR-TB is resistant to at least 2 drugs including INH + RIF
PZA + EMB + FQ + AG +/- alternative agent for 16 - 24 months Usable AG's are streptomycin, amikacin, kanamycin |
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"alternative agents" for TB?
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cycloserine
ethionamide clarithromycin ampicillin/clavulanic acid linezolid streptomycin |
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Use DOT for _________.
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regimens dosed less often than daily
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non-pharmacologic protocol with active TB
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pt should be isolated in single, negative pressure room
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Isoniazid MOA
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inhibits cell-wall synthesis of susceptible isolates
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isoniazid administration
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1 hour before or 2 hours after a meal on EMPTY STOMACH
increase dietary intake of folic acid, niacin and magnesium while taking INH |
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isoniazid adverse effects
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BLACK BOX WARNING: severe and fatal hepatitis may occur, usually within first 3 months of treatment.
CONTRAINDICATED in acute liver disease. ADVERSE EFFECTS: increased LFT's, hepatitis, peripheral neuropathy, lupus-like syndrome, agranulocytosis, nausea, hypersensitivity |
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rifampin MOA
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inhibits RNA synthesis by blocking RNA transcription
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rifampin adverse effects
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flu-like syndrome, rash, hepatotoxicity
N/V/D hyperbilirubinemia, leukopenia, thrombocytopenia renal failure, increased uric acid ORANGE/RED DISCOLORATION OF BODY FLUIDS (will stain contact lenses) |
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ethambutol MOA
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suppresses Mycobacteria replication by interfering with RNA synthesis
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ethambutol adverse effects
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OPTIC NEURITIS, decreased visual acuity, color blindness (usually reversible)
rash, N/V increased uric acid headache, confusion, hallucinations MONITOR with vision tests MONTHLY! dose adjust in renal impairment |
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pyrazinamide MOA
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converts to pyrazinoic acid in Mycobacterium, which decreases pH
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pyrazinamide adverse effects
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hepatotoxicity
N/V, rash arthralgia, myalgia, malaise increased uric acid CONTRAINDICATED in acute gout, and severe hepatic damage dose adjust in renal impairment |
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streptomycin MOA
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binds to 30S ribosomal subunit and inhibits bacterial protein synthesis
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streptomycin adverse effects
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BLACK BOX WARNING: neurotoxicity, nephrotoxicity, neuromuscular blockade and respiratory paralysis
IV form can cause ototoxicity |
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Which 4 tuberculosis drugs have the most significant drug interaction profiles?
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Isoniazid
Rifampin Pyrazinamide Streptomycin |
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INH drug interactions
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major 3A4 and 2C19 inhibitor
moderate 2D6 inhibitor AVOID with alfluzosin, eplerenone, ranolazine, salmeterol, nisoldipine, alcohol can increase levels of phenytoin, carbamazepine, benzodiazepines avoid with tyramine and histamine containing foods |
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RIF drug interactions
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potent INDUCER of 3A4, 2C19, 2C9, 1A2 and 2C8
avoid with protease inhibitors, mycophenolate, ranolazine, voriconazole and alcohol can decrease levels of warfarin, methadone, sulfonylureas, calcium channel blockers, digoxin, cyclosporine, amiodarone and many others |
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PZA drug interactions
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can increase RIF (can cause fatal hepatotoxicity, monitor LFTs, uric acid, etc.)
can decrease cyclosporine |
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Streptomycin interactions
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increases effect with neuromuscular blocking agents
increases nephrotoxicity with amphotericin B, cisplatin, loop diuretics, NSAIDs and vancomycin |
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With which TB drug should you take dietary supplements, which ones, and why?
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pyridoxine (Vit B6): 10 mg for every 100 mg of INH, administered concurrently (INH depletes pyridoxine by forming a complex with it that is excreted in urine, causes NEUROPATHY)
INH decreases absorption of folic acid, niacin and magnesium |
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Which TB drug can cause a preventable neuropathy, and how can it be prevented?
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INH - forms a complex with pyridoxine (vit B6) which is excreted in the urine
supplement with 10 mg pyridoxine for every 100 mg INH, administered concurrently |
