Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCLTBI treatment: precautionsPersons with any of the conditions outlined below should be referred to a respiratory clinician or infectiousdisease consultant for treatment of LTBI:• Acute or chronic liver disease of any aetiology• Acute liver disease: If a person with acute liver disease has a high risk of progression to TB diseasefor example if the person is on immunosuppressive therapy and also had prolonged contact with ahighly infectious TB case, then a risk assessment should be carried out to determine whether theyshould be treated for LTBI• Receiving other drugs which may interact with anti-TB drugs• History of heavy alcohol ingestion• History of previous discontinuation of isoniazid because of possible, but not definite, related sideeffects e.g. headaches, dizziness, nausea• Major concerns about adherence to treatment• Major concerns about adherence to arrangements for biochemical or clinical monitoring• Peripheral neuropathy or risk factors for its development e.g. insulin dependent or type II diabetes,alcoholism, chronic renal failure or malnutrition. Pyridoxine 10mg daily (or 20mg if 10mg notavailable) should be offered to these patients (see section on pyridoxine).Recommendation:A consultant with expertise in TB should always be consulted when treating a patient with LTBIwith documented hepatotoxicity.A risk-benefit approach on a case-by-case basis should be adapted to commencing treatment for LTBI onthese patients. Treatment of patients with underlying liver disease should be undertaken in consultationwith a consultant hepatologist.Recommendation:Breastfeeding is not a contraindication to LTBI therapy. Isoniazid or rifampicin are not secretedin sufficient quantities in breast milk to harm the baby. 52;77Monitoring during treatmentClinical monitoring is indicated for all patients and ideally involves monthly visits, or at the discretion ofthe physician, where patients are educated about the symptoms and signs that can result due to adverseeffects of the drug(s) being prescribed and the need for prompt cessation of treatment and clinicalevaluation should symptoms occur.The symptoms of adverse affects include: 34;52• unexplained anorexia• nausea• vomiting• dark urine• jaundice• rash• persistent paresthesia of the hands and feet• persistent fatigue-39-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC• weakness or fever lasting three or more days• abdominal tenderness (especially right upper quadrant discomfort)• easy bruising or bleeding and• arthralgia.The interval between commencing isoniazid and the appearance of hepatitis varies widely. Using astandardised proforma may facilitate monthly clinical monitoring (appendix 5). Appropriate educationalmaterials (information leaflet) in the patient’s language should be provided (appendix 6).Liver function tests (LFTs)Monthly LFTs during treatment of LTBI are indicated for patients whose baseline liver function tests areabnormal and for all HIV-infected persons, pregnant and post-partum women (up to 2-3 months postpartum),those with a history of hepatitis, liver disease or heavy alcohol ingestion, injecting drug users andthose on treatment with other potential hepatotoxic agents. 77Some experts recommend that healthy adults aged >35 years on LTBI treatment with isoniazid or isoniazidwith rifampicin have eight weekly monitoring of LFTs or at one, three and six months for those on a ninemonth regimen. The frequency depends on the perceived hepatotoxicity risk and effectiveness of patienteducation. 108In addition, laboratory testing (e.g. liver function studies for patients with symptoms compatible withhepatotoxicity or a uric acid measurement to evaluate patients who develop acute arthritis) should be usedto evaluate possible adverse effects that occur during the course of treatment.Interventions for hepatotoxicity during treatment for LTBIIf hepatic side-effects occur during treatment, expert advice should be sought from the treating physician.A hepatology evaluation should be undertaken and hepatology consultation is recommended for unusualor severe cases of hepatitis particularly those who become sufficiently ill to require hospitalisation. 108Isoniazid should be withheld if hepatic transaminases (ALT) are at least three times the ULN when thepatient is symptomatic (jaundice or symptoms of hepatitis) or if at least five times the ULN when the patientis asymptomatic. An isoniazid rechallenge should be considered when the ALT is less than twice the ULN.This should be decided by the treating physician on a case-by-case basis.A rapid increase in ALT may be an indication for more frequent monitoring i.e. every two weeks instead ofmonthly, particularly if one of the above treatment-limiting ALT thresholds is being approached or if thepatient has previously identified risk factors for hepatotoxicity.For the few patients who may begin isoniazid LTBI treatment with a baseline ALT >3 times the ULN, someexperts recommend that in the absence of adequate clinical data that treatment should be discontinuedif there is more than a two- to threefold increase above baseline or if there is a mental status change,jaundice or significant increase in bilirubin or INR. 108More detailed information on the hepatoxicity of anti-TB therapy is available in the Official AmericanThoracic Society’s Statement: Hepatotoxicity of Anti-TB Therapy. 108Recommendation:Ideally monthly clinical monitoring (at the discretion of the clinician) is recommended for allpatients receiving treatment for LTBI.-40-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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