Guidelines for chemotherapy of tuberculosis in Taiwan

Guidelines for chemotherapy of tuberculosis in Taiwan

馬偕紀念醫院 一般內科及感染科主治醫師 曾祥洸 2005-3-9

Infectious Disease Society of TaiwanThe Society of Tuberculosis, TaiwanMedical Foundation in Memory of

Dr. Deh-Lin Cheng (J Microbiol Immunol Infect 2004;37:282-384)

Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Educatio

nCY Lee’s Research Foundation for Pediatric I

nfectious Diseases and Vaccines

Three principles for the guidelines

1. From the viewpoint of primary care physician

2. Antimicrobial agents recommended already marketed in Taiwan

3. Base on academic principles rather than the regulation of the Bureau of National Health Insurance

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

New Case

Pulmonary tuberculosis Drugs of choice for New case

• 1. Standard regimen: (total 6 months)• INH+RIF+EMB+PZA for 2 months,• Then INH+RIF+EMB for 4 months

• 2. Fixed-dose combinations: (total 6 months)• Rifater+EMB for 2 months• Then Rifinah+EMB for 4 months

cavitations on initial chest X ray and/or positive cultures at completion of initial 2 months’ treatment, extend treatment to total 9 months.

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

Retreatment

Pulmonary tuberculosis

Drugs of choice for

Retreatment (total 8 months)• 1. Relapse 2. Default 3. Failure

• INH+RIF+EMB+PZA+IA for 3 months,

• Then INH+RIF+EMB for 5 months

IA: Injectable aminoglycosides include streptomycin, kanamycin, and amikacin, and should be administered in the initial 2 months of treatment

Retreatment1. Relapse is defined as a patient who

develops active tuberculosis (by culture, clinical or radiological deterioration) after completion of anti-tuberculous therapy.

2. Default is defined as interruptions in therapy of longer than 2 months.

3. Failure is defined as continued or recurrent positive cultures after 4 months of treatment in patients with assured adherence to the prescribed anti-tuberculous regimen.

Pulmonary tuberculosis

Culture and susceptibility testing should be done immediately and regimen should be tailored to susceptibility testing results.

Referral to specialists in Infectious diseases, chest medicine or experts on tuberculosis is recommended.

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

Drugs Resistance

and Drugs Intolerance

Drug resistance to INH

RIF+EMB+PZA

for 6 months

RIF+EMB+PZA

+IA

for 6 months

Drug intolerance to INH

RIF+EMB+PZA

for 6 months

Drug resistance to RIF

INH+EMB+PZA

for 9-12 months

INH+EMB+PZA+IA +/- FQ for 9 months

Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin.

Drug intolerance to RIF

INH+EMB+PZA

for 9-12 months

INH+EMB+PZA+IA +/- FQ for 9 months

Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin.

Drug resistance to EMB

INH+RIF+PZA

for 2 months,

then

INH+RIF

for 4 months

(total 6 months)

--

Drug intolerance to EMB

INH+RIF+PZA

for 2 months,

then

INH+RIF

for 4 months

(total 6 months)

--

Drug resistance to INH, RIF (MDR-TB):

EMB

+PZA

+IA

+FQ

+TBN (本院無 ) (prothionamide)

for 18-24 months*

--

*Treatment duration is a total of 18 months after sputum conversion.

Drug resistance to INH, RIF, EMB (MDR-TB):

PZA

+IA

+FQ

+TBN (本院無 ) (prothionamide)

+PSA (本院無 )

for 18-24 months*

--

*Treatment duration is a total of 18 months after sputum conversion.

Drug intolerance to PZA

INH+RIF+EMB

for 9 months

--

Drug intolerance to INH, RIF :

EMB

+PZA

+IA

+FQ

+TBN (本院無 ) (prothionamide)

for 18-24 months*

--

*Treatment duration is a total of 18 months after sputum conversion.

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

3 Special situations

Liver function impairment and/or liver cirrhosis

RIF+EMB+PZA

for 6 months

Or

INH+RIF+EMB

for 9 months

RIF+EMB+IA+FQfor 12-18 months

Or

EMB+TBN (本院無 ) (prothionamide) +IA+FQfor 18-24 months

Renal function impairment is defined as Ccr<30mL/min or ESRD

INH+RIF+

EMB*+PZA*

for 2 months

then

INH+RIF+ EMB*

for 4 months

(total 6 months)

INH+RIF+EMB+PZA

for 2 months

then

INH+RIF+EMB

for 4 months*

*Intermittent dosing

(total 6 months)

Pregnancy or breastfeeding

INH+RIF+EMB+PZA

for 2 months

then

INH+RIF+EMB

for 4 months

(total 6 months)

INH+RIF+EMB

for 9 months

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

Dosage of antituberculous agents

(for adult only)

Dosage of antituberculous agents (for adult only) INH (100 mg)

RIF (150; 300 mg)

EMB (400 mg)EMB*

PZA (250 mg)PZA*

5 mg/kg BW qd (maximum 300mg)

10 mg/kg BW qd (maximum 600mg)

15-25 mg/kg BW qd15-25 mg/kg BW qod

15-30 mg/kg BW qd (maximum 2 g)12-25 mg/kg BW qd

Intermittent dosing (3 times weekly) after hemodialysis

INH (100mg)

RIF (150; 300 mg)

EMB (400 mg)

PZA (250 mg)

900mg

600mg

15-25 mg/kg BW

25-35 mg/kg BW

Dosage of antituberculous agents (for adult only)

Streptomycin (1g) amikacin (250mg)

kanamycin (本院無 )

Ciprofloxacin (250mg)

Levofloxacin (100mg)

Ofloxacin (本院無 )

15 mg/kg BW qd

500-750 mg bid 500mg qd 400mg bid

Dosage of antituberculous agents (for adult only)

TBN (本院無 )

PAS (本院無 )

15-20 mg/kg BW, divided to bid-tid (maximum 1 g)

200 mg/kg BW, divided to bid-qid

Dosage of antituberculous agents (for adult only)

Rifater

(INH 80 +RIF 120 +PZA 250)

Rifinah-300 (本院無 )

(INH 150 +RIF 300 )

Rifinah-150 (本院無 )

(INH 100 +RIF 150 )

1 tab/10kg BW qd (maximum 5 tab)

2 tab qd,

if BW > 50 kg BW

3 tab qd,

if BW < 50 kg BW

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

Extrapulmonary tuberculosis

Pleurisy, Lymphadenitis, Peritonitis (intestinal disease), Pericarditis, Genito-urinary tract disease

INH+RIF+EMB+PZA

for 2 months

then

INH+RIF+EMB

for 4 months

(total 6 months)

--

Bone and joint diseases, pleural empyema

INH+RIF+EMB+PZA

for 2 months

then

INH+RIF+EMB

for 7 months

(total 9 months)

--

Meningitis, CNS disease

INH+RIF+EMB+PZA

for 2 months

then

INH+RIF+EMB

for 10 months

(total 12 months)

--

Steroids

Prednisolone < 1 mg/kg BW qd or equivalent for a minimum of 3 weeks

Recommended in

Pericarditis

Meningitis

CNS disease

Topics not included

1. TB - HIV coinfection 2. Drug-drug interaction 3. Other antituberculosis drugs (rifabutin,

cycloserine) 4. Treatment of the pediatric population

Guidelines for chemotherapy of tuberculosis in Taiwan

(J Microbiol Immunol Infect 2004;37:282-384)

Thanks for yours attention!