Guidelines on the Prevention and Control of Tuberculosis in Ireland

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B<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCof DILI include the degree of baseline ALT elevation, alcohol consumption, increasing age and evidence ofactive replication of the hepatitis virus.If LTBI treatment is started, some experts recommend measuring the serum transaminases and bilirubinconcentrations every 2 to 4 weeks for the first 2 to 3 months of treatment. The international normalisedstandard (INR) may be followed periodically as well in patients with severe hepatic impairment. 108Figure 3.1: Latent tuberculosis infection (LTBI) pretreatment clinical evaluation and counselling*Potential eligible patient for LTBItreatment based on risk factorsRe-evaluateHepatology evaluationYesDefer treatmentIdentify risk factors for hepatotoxicity, ask if :Chronic alcohol consumptionViral hepatitisPre-existing liver disease2-3 months post-partumConcomitant hepatotoxic medicationsPrevious ALT/AST or LFTs abnormalHIV infectedAge >35YesCheck baselineALT/AST andbilirubinYesALT/AST or LFTs >= 3 xULN if symptomatic, >=5x ULN if asymptomaticDefer LTBItreatment until 2-3months postpartumNoLow riskAssess TB risk(Treat pregnant patientwho is HIV-positive, closecontact or documentednew converter)YesPregnantNoHigh riskCheck ALT/AST and LFTsprior to beginning treatmentand follow closelyNoRegimen selection according to indication and risk of drug-induced liver injury:Isoniazid x 6 months, 9 months optimalRifampicin x 4 months (6 months in children) e.g. if ALT 2-3 x ULN, isoniazidresistanceor hepatotoxicity, need to complete treatment in short timeCombination of rifampicin and isoniazid x 3 months, 4 months optimal (4 monthsin children)Patient educationUse patient’s preferred languageReview hepatitis symptoms and signsDiscontinue treatment at symptom onset and contactclinicDocument patient education in chartMonitoring plan inmedical recordALT = alanine aminotransferase; AST = aspartate aminotransferase; LFTs = liver function tests; ULN = upper limit of normal* Adapted from the New York City Department of Health and Mental Hygiene TB guidelines-35-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC3.7 Drug Regimens for LTBIIsoniazid is used alone for preventive therapy for a minimum of six months with an optimum duration ofnine months. The drug is given in a single daily dose of 5mg/kg (max dose: 300mg) per day for adults and5-10mg/kg (max dose: 300mg daily) for children. 77 Ideally, anti-TB therapy for the treatment of LTBI shouldbe dispensed in monthly allocations. However in some situations, if the clinician or public health doctordeems it appropriate it may be dispensed at less frequent intervals e.g. every two months. If isoniazidcannot be given daily, it can be given twice weekly in a dose of 15mg/kg (up to 900mg) for adults and 20-30mg/kg (up to 900mg) for children (see table 3.4). 77;109For persons intolerant to isoniazid or who are likely to be infected with isoniazid resistant organisms,rifampicin for four months may be used (see table 3.4).Dosages for drugs commonly used for treatment of LTBI are outlined in table 3.4. For treatment with otherdrugs, referral to a clinician experienced in TB is advised, particularly for contacts of MDR-TB cases (section3.5).Table 3.4: Drug Regimens for LTBIDrug anddurationDailyDosageTwice weeklyMajor adverse reactionsRecommendedmonthly monitoring 1CommentsIsoniazidChildren:6 monthsoptimumAdults:9 monthsoptimumChildren:5-10mg/kg(max 300mg)Adults:5mg/kg(max 300mg)CompletionCriteria:270 doseswithin 12monthsChildren:20-30mg/kg(max 900mg)Adults:15mg/kg(max 900mg)CompletionCriteria:76 doseswithin 12 monthsSymptoms: Unexplainedanorexia, nausea, vomiting,dark urine, jaundice, persistentfatigue, weakness, abdominaltenderness (especially rightupper quadrant discomfort),easy bruising or bleeding, rash,persistent paresthesias of thehands and feet, arthalgiaSigns: Elevated LFTs, hepatitis,icterus, rash, peripheralneuropathy, increased phenytoinlevels and possible interactionwith disulfiramClinical evaluation: LFTs (ifbaseline is abnormal or patienthas risk factors for toxicity) 2Preferred regimenfor all individualsVitamin B6 (25mg/day)or pyridoxine maydecrease peripheraland CNS effects, andshould be used inpatients who are:- Abusing alcohol- Pregnant- Breastfeeding infantson isoniazid- MalnourishedOr who have- HIV- Cancer- Chronic renal or liverdisease- Diabetes- Pre-existingperipheralneuropathyNote: aluminiumcontainingantacidsreduce absorption-36-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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