PRINCIPLES IN MANAGING TB

IN SPECIAL CONDITIONS
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Learning Objectives

By the end of the session, the participant will be

able to:
 Identify special conditions that may require
attention during TB treatment
 Administer the appropriate TB regimen under
special conditions/ situations
 Monitor patients with special
conditions/situations receiving TB treatment

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 General considerations
Patients with comorbid conditions needs special
considerations during treatment of DR-TB with SDLs
as there could be:
– Potential toxicity of second line drugs to the foetus or
breast feed infants
– Drug-drug interactions between drugs used for DR-TB
and certain comorbid condition
– Worsening of symptoms, toxicity and control of comorbid
condition or their complication due to concomitant SLD
administration
– Barrier to adherence to treatment
– Need for modification of drugs used for either or both
conditions 3
Special Conditions for Treatment
• Pregnancy
• Breastfeeding
• Contraception
• Co-morbidities
– Diabetes mellitus,
– Renal insufficiency,
– Liver disorders,
– Seizure disorders,
– Psychiatric disorders,
– Substance dependence
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Breast  A woman who is breastfeeding and has active drug-resistant TB
Feeding should receive a full course of anti-tuberculosis treatment.
 Timely and properly applied chemotherapy is the best way to
prevent transmission of tubercle bacilli to her Baby.
 The amount excreted in Breast milk neither treats TB nor causes
toxicity to the nursed infant.
 Breast milk is often the best and the only feasible feeding option
for most infants in Ethiopia.
Family  Family planning service should part of DR TB patient care
Planning  Oral contraceptives are not recommended due to possible
interactions & side effects like nausea and increased pill burden.
 Medroxyprogesterone (Depo-Provera) administered by
intramuscular injection every 12 weeks or placement of an
intrauterine device (IUCD) or implants (e.g. Implanon) are preferred
options.
 In addition to other contraceptives Condoms use should be
promoted to protect against Sexually transmitted diseases including
HIV 6
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Renal Insufficiency

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Table 9.2 continued

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 TB/HIV co-management
• There are two scenarios in MDR-TB/HIV Co-
management:
– If Patient is not on ART when diagnosis of DR-
TB confirmed, and
– If Patient is already on ART when diagnosis of
DR-TB confirmed:

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If Patient is not on ART when diagnosis of DR-TB
confirmed:

 Start standard regimen for MDR-TB

 Initiate Co-trimoxazole preventive therapy and ART regardless of CD4
level as soon as patient tolerates DR-TB treatment within 8 wks
 Preferred regimen AZT+3TC+EFV/NVP (Avoid TDF in intensive
phase)
Note: DS-TB same consideration but regimen TDF + 3TC + EFV

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If Patient is already on ART when diagnosis of DR-TB
confirmed:
 Might indicate IRIS if ART < 6 months or treatment failure if develops after 6
months of ART. CD4 count & viral load helps to differentiate the problem.
 If a patient develops MDR-TB while on ART:
 Rule out ART treatment failure if the patient has been on ART for longer than
6 months.
 In case there is evidence of ART failure, consider switching to second line
regimen.
 Start the standard treatment for MDR-TB with no delay
 Substitute TDF by AZT to avoid concomitant administration with injectable
SLDs to avoid possible overlapping nephrotoxicity.
 TDF may be resumed once the Injectable is discontinued.
 Note: DS-TB same consideration but regimen TDF + 3TC + EFV
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