The combination of drugs used is mainly the same irrespective of the location of tuberculous changes in the body. The choice of medication is affected by the possibility of drug resistance and any previous treatment; the duration of treatment depends on the location of tuberculous changes.
Depending on the local policies, the medication, hospital treatment and/or follow-up visits required for the treatment of tuberculosis may be free of charge for the patient.
The standard treatment regimen consists of rifampicin (RIF) and isoniazid (INH) for 6 months, combined with ethambutol (EMB) and pyrazinamide (PZA) during the first 2 months.
Regular intake of the drugs is essential for treatment success.
Some information in this article describes the organization and implemenation of care in Finland. Consult also local (national, regional) guidelines concerning the use of antitubercular medication.
The organization of care may be directed by national legislation and other policies. Consult them for locally relevant details.
In Finland, for example, the treatment of tuberculosis is started and monitored within specialized care. Supervised outpatient care is carried out within primary care in collaboration with specialized care.
Except for certain patient groups (e.g. patients with AIDS), the standard treatment regimen consists of rifampicin (RIF) and isoniazid (INH) for 6 months, combined with ethambutol (EMB) and pyrazinamide (PZA) during the first 2 months.
The normal daily dose for RIF is 600 mg (450 mg for patients under 50 kg), for INH 300 mg, for PZA 1 500 mg (1 000 mg for patients under 55 kg and 2 000 mg for patients over 75 kg), and for EMB 1 250 mg (750 mg for patients under 55 kg and 1 600 mg for patients over 75 kg), respectively.
Fluoroquinolones should not be used as first-line antitubercular drugs, but in skeletal tuberculosis they are recommended and they may be necessary also in specific casesFluoroquinolones for Treating Tuberculosis.
The treatment of central nervous system tuberculosis Meningitis in Adults should be started as soon as meningeal tuberculosis is suspected because it will take time to obtain the result of bacterial culture. Fluoroquinolone is usually incorporated into the treatment.
GPs and specialists in other fields should take the patient's antitubercular medication into consideration.
Symptoms or laboratory findings may be due to the medication.
Interactions with other medicines should be considered (warfarin treatment should be reviewed when starting or ending the administration of RIF).
All drugs should be taken at the same time, in the morning. Regular intake of the drugs is the most important prerequisite for recovery.
Supervised medication
Supervised medication should be organized for all patients. Patients should take (swallow) their medication under the supervision of a nurse or video surveillance. Since tuberculosis is usually defined as a dangerous communicable disease, specific regulations with regard to the treatment apply. Consult local instructions.
In Finland, supervised medication is, as far as possible, carried out 7 days a week particularly in drug- or alcohol-addicted patients, in elderly patients and in patients with multiple problems. In other patients, supervised medication is carried out on 5 days a week (Monday to Friday).
What supervised medication involves
Encouragement and motivation of patients throughout treatment
Teaching patients and those responsible for treatment about the administration of medication, particularly emphasizing that it should be administered regularly every day
Checking that the medication is administered as prescribed
Supervising and recording that patients swallow their medication, and regular reporting of this to the unit responsible for their treatment
Monitoring of the adverse effects of medication and quick response to such effects, as necessary
Recording of any deviations in therapy and reporting of such deviations to the unit responsible for treatment
Telling patients that supervised medication is part of the good treatment of tuberculosis, aimed at supporting the patient, and does not represent a doubt about the patient's reliability.
Supervised medication under video surveillance can be either live or recorded. In the latter case, a nurse can check afterwards that the medication was taken.
Adverse effects of antitubercular drugs
Always consult locally available drug information regarding interactions and adverse effects of antitubercular drugs.
Rifampicin
Stains all excretions red (may stain contact lenses).
Liver reactions
Gastrointestinal symptoms
Skin symptoms
Immunologically mediated symptoms
Flu-like syndrome
Thrombocytopenia
Haemolytic anaemia
Anuria
Shock, dyspnoea
Interactions occur with the following pharmaceutical agents, for example (impairing their efficacy):
oral contraceptives
anticoagulants
glucocorticoids
tolbutamide
barbiturates
cyclosporin.
Isoniazid
Liver reactions
Rash
Fever
Neurological symptoms
Peripheral neuropathy
Convulsions, psychological symptoms
Ethambutol
Optic neuritis; visual acuity and colour vision may be impaired
Rash
In patients with renal failure, the dose should be reduced.
Pyrazinamide
Liver reactions
Arthralgias (asymptomatic increase in serum urate concentration is more common)
Gastrointestinal symptoms
Sensitization to sunlight
Flush
Nausea
Investigations during treatment
Check local instructions regarding follow-up.
Laboratory tests
At treatment start
ESR, basic blood count with platelets, plasma ALT, alkaline phosphatase, bilirubin, creatinine,CRP, HIV antibodies
After 2 weeks and 1, 2, 4, and 6 months from treatment start and as indicated
if EMB is used, visual acuity and colour vision before beginning the medication, 2 weeks after the beginning and subsequently once a month.
Chest x-rays for follow-up of pulmonary tuberculosis
Before the treatment, 2 and 6 months after starting treatment, and as indicated on clinical grounds (suspicion of poor response, for example).
Sputum smear microscopy and sputum culture in pulmonary tuberculosis
Before treatment, also for determination of drug resistance
Tb staining and culture of sputum should be performed at 2 weeks and subsequently once a month in series of 3 samples.
Other samples should be taken as clinically indicated.
Patients can be considered cured after adequate treatment and no routine follow-up examinations are indicated. If problems occurred in the treatment or if substantial changes remain in the chest x-ray or if the patient is HIV-positive, the follow-up may be continued for 1-2 years after the treatment.
Treatment of latent infection in adults
About a third of the population worldwide has been infected with tuberculosis. These people have a latent tuberculosis infection (LTBI) but no symptoms or active disease.
The life-time cumulative risk of developing tuberculosis is about 10%, and in half of cases this occurs within 2 years of infection.
The assessment concerning the need for treatment is performed in specialized care.
Treatment of latent tuberculosis infection should be considered if the risk of developing symptomatic disease is increased, for example, if initiation of TNF-alpha inhibitor treatment is planned.
Treatment of asymptomatic LTBI should also be considered after recent significant exposure to tuberculosis. In such cases, antitubercular treatment is used to prevent symptomatic disease after primary infection.
The treatment of patients with LTBI should always be started, monitored and ended in specialized care.
Consult local instructions regarding the investigations and treatment of persons exposed to tuberculosis.
Treatment alternatives
A combination of INH and rifampicin (RIF). Dosage of INH: for adults 300 mg daily and for children 10 mg/kg daily. Dosage of RIF: for adults 450 mg (≤ 50 kg) or 600 mg (>50 kg) daily and for children 10-20 mg/kg daily. The duration of treatment is 3 months.
Check local epidemiology (including nearby countries) and local guidelines.
Effective and regular medication prevents the development of drug resistance.
Multiresistant strains are therefore so far rare in Finland but they do occur close to Finland, in Russia and in the Baltic countries, as well as in countries where the treatment of tuberculosis is inadequate.
If the patient has received antituberculous drugs in the past, if there is no reliable record of the treatment, if the medication has been discontinued, or if the patient arrives from a region where drug resistance is common, the risk of drug resistance must be taken into account when the treatment is planned
When drug resistance is suspected, a stain-positive sputum sample is always tested using a rapid test based on nucleic acid detection in order to detect drug resistance. The test may also be perfomed in a stain-negative sputum sample, but in such a case its sensitivity is not as good. A culture with growth can also be examined using a rapid test based on nucleic acid detection, but the actual results regarding sensitivity to different drugs is only acquired through the culture method.
Simply adding a further drug if the disease responds poorly to the combination of drugs used represents malpractice!
Patients with multiresistant tuberculosis should be treated, in the infectious stage, in an isolated, hypobaric space. The treatment is long and expensive.