Guidelines on the Prevention and Control of Tuberculosis in Ireland

More documents

Recommendations

Info

<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCInterruptions in therapyAdherence to treatment regimens is recognised as a significant problem, especially in relation to thetreatment of LTBI, with CDC stating that only 60% of patients who start treatment for LTBI complete atleast six months of treatment. 34 The length and complexity of the regimen and the side effects of themedication influence adherence to treatment. Directly observed therapy (DOT) has been used to try toimprove adherence to treatment regimens. Ideally, patients should receive medication on a regular dosingschedule until completion of the indicated course. However, in practice some doses may be missed,requiring the course to be lengthened.If interruptions in therapy occur the person responsible for supervision must decide whether to restart acomplete course of treatment or whether simply to continue as originally intended.Completion of therapy is based on the total number of doses administered not on the duration of therapyalone. The nine month regimen of daily isoniazid should consist of a minimum of 270 doses administeredwithin 12 months, which allows for minor interruptions in therapy. The six month regimen of isoniazidshould consist of at least 180 doses administered within nine months. 34When therapy is restored after an interruption of more than two months, a medical examination to rule outactive TB disease is indicated.3.8 Risk of TB Associated with the Use of TNF-α AntagonistsTNF-α antagonists offer great promise to patients suffering a number of immune-mediated diseases andhave been used safely in many patients worldwide. However, it is plausible that these agents may carrya risk of reactivation of LTBI or of new TB infection. Concern is supported by the finding of a possibleincreased risk of TB in peer-reviewed publications from a number of countries. While the design ofthese studies does not allow causality to be concluded, the consistency of the studies and the temporalassociation with the agents, together with the gravity of the consequence for individual patients and forthe wider community suggest that a precautionary approach is appropriate. Manufacturers of TNF-αantagonists have indicated that TB is a possible side effect of treatment and a number of guidelines formanagement of this risk have been issued by professional organisations and individuals.The following recommendations (summarised in figure 3.2) are taken from a briefing paper preparedby members of the National TB Advisory Committee in consultation with members of the IrishSociety for Rheumatology. The full version of this document is available at: www.hpsc.ie/hpsc/A-Z/VaccinePreventable/TuberculosisTB/Guidance/.1. Prior to commencing TNF-α antagonists, patients should be thoroughly assessed for clinically activeTB disease, including clinical history, physical examination and chest radiograph. If clinically active TBdisease is diagnosed, it should be treated as per existing guidelines (chapter 5).2. Patients without clinically active TB disease should be screened for LTBI with clinical history, assessmentof risk factors (for example time spent living in a high incidence country, immunocompetence, etc.),physical examination, chest radiograph and TST.• IGRA testing may be a useful adjunct in screening where it is available.3. Patients without radiographic evidence of TB but with a positive TST should be classified as a case ofLTBI.• For the purpose of LTBI screening prior to commencing TNF-α antagonists, 2TU Mantoux testingis recommended. While reactions over 10mm should be interpreted as indicating TB infection,this cut off may not be reliable for some patients being considered for treatment with TNF-αantagonists since their disease and co-medications may lead to anergy. Therefore, the use of a5mm cut-off may be more useful for patients who are considered to be immunocompromised. It-41-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCis recognised that on the basis of individual risk assessment, clinicians may prefer to use an evenmore conservative cut-off for individual patients. Although a negative TST (Mantoux test) reducesthe probability of LTBI, a high clinical suspicion for LTBI should be maintained, since the reaction totuberculin may be complicated by anergy.• It is recommended that the interpretation of Mantoux testing in the context of testing for LTBIprior to commencement of a TNF-α antagonist should not usually take account of the patient’sBCG history.4. It is recommended that patients diagnosed with LTBI should be treated. Options for treatment includeat least nine months of isoniazid, which is associated with a lower risk of hepatotoxicity, or four monthsof rifampicin (R) +/- isoniazid, associated with a higher risk of hepatotoxicity but offers the advantageof shorter duration which may promote successful completion of treatment for some patients.Rifampicin for four months may also be used if isoniazid is contraindicated e.g. a past history of anisoniazid induced reaction. Pyridoxine may also be used in combination with these regimens.5. Optimal timing of initiation of TNF-α antagonists is challenging and in the absence of high-qualityevidence to support specific recommendations in this regard, decisions on the treatment of individualpatients need to be made collaboratively by patients and clinicians following a careful assessment ofthe risks of TB disease and the benefits of TNF-α antagonist treatment and discussion of individualpreferences.• Initiation of TNF-α antagonists prior to commencement of treatment of clinically active TB diseaseor LTBI should be avoided• The risk associated with commencement or re-commencement of TNF-α antagonists in thesetting of clinically active TB disease requires particularly careful assessment; where possible,it is recommended that TNF-α antagonists be postponed until curative treatment has beensatisfactorily completed; in some cases, clinicians and patients may prefer to avoid TNF-αantagonists completely in this scenario• The risk associated with commencement or re-commencement of TNF-α antagonists in thesetting of LTBI also requires careful assessment; again, where possible, it is recommended thatTNF-α antagonists be postponed until LTBI treatment has been satisfactorily completed. However,clinicians and patients may, on balancing risks and benefits, prefer to initiate TNF-α antagonistsduring treatment for LTBI; while no specific duration of LTBI treatment prior to initiation of TNF-αantagonists can be recommended on the basis of currently available evidence, where possible, alonger duration of satisfactory LTBI treatment is suggested as good practice in managing the riskof initiation of TNF-α antagonists.6. Clinically active TB disease may still arise in patients treated with TNF-α antagonists despite a negativeinitial assessment or LTBI treatment. Therefore, it is recommended that a high index of clinical suspicionfor development of TB is exercised in the setting of any clinical deterioration while patients areundergoing TNF-α blockade.7. Cooperation between clinicians initiating TNF-α antagonists and clinicians with expertise in TB isrecommended in the assessment and management of patients.8. Clinicians are encouraged to report all adverse drug events associated with the use of TNF-αantagonists to the Irish Medicines Board (IMB).It is suggested that these national recommendations provide a framework for the drafting of guidelinesfor use by individual professional societies, units and clinicians on the use of TNF-α antagonists in clinicalguidance; it is recognised that such guidelines may have broader concerns than the management of therisk of TB (e.g. surveillance for other side effects) and may wish to include local good practice advice,however, guidelines should be made cognisant of these recommendations.-42-
Page 2 and 3:
Guidelines on the
Page 4 and 5:
Guidelines on the
Page 6 and 7:
Guidelines on the
Page 8 and 9:
Guidelines on the
Page 10 and 11: Guidelines on the
Page 54 and 55: BGuidelines on the
Page 70 and 71: 1♦Guidelines on
Page 98 and 99: Figure 6.1Patient placement for Pul
Page 110 and 111:
Guidelines on the
Page 112 and 113:
Guidelines on the
Page 114 and 115:
Guidelines on the
Page 116 and 117:
Guidelines on the
Page 118 and 119:
Guidelines on the
Page 120 and 121:
Guidelines on the
Page 122 and 123:
Guidelines on the
Page 124 and 125:
Guidelines on the
Page 126 and 127:
Guidelines on the
Page 128 and 129:
Guidelines on the
Page 130 and 131:
Guidelines on the
Page 132 and 133:
Guidelines on the
Page 134 and 135:
Guidelines on the
Page 136 and 137:
Guidelines on the
Page 138 and 139:
Guidelines on the
Page 140 and 141:
Guidelines on the
Page 142 and 143:
Guidelines on the
Page 144 and 145:
Guidelines on the
Page 146 and 147:
Guidelines on the
Page 148 and 149:
Guidelines on the
Page 150 and 151:
Guidelines on the
Page 152 and 153:
Guidelines on the
Page 154 and 155:
Guidelines on the
Page 156 and 157:
Guidelines on the
Page 158 and 159:
Guidelines on the
Page 160 and 161:
Guidelines on the
Page 162 and 163:
Guidelines on the
Page 164 and 165:
Guidelines on the
Page 166 and 167:
Guidelines on the
Page 168 and 169:
Guidelines on the
Page 170 and 171:
Guidelines on the
Page 172 and 173:
Guidelines on the
Page 174 and 175:
Guidelines on the
Page 176 and 177:
Guidelines on the
Page 178 and 179:
Guidelines on the
Page 180 and 181:
Guidelines on the
Page 182 and 183:
Guidelines on the
Page 184 and 185:
Guidelines on the
Page 186 and 187:
Guidelines on the
Page 188 and 189:
Guidelines on the
Page 190 and 191:
Guidelines on the
Page 192 and 193:
Guidelines on the
Page 194 and 195:
Guidelines on the
Page 196 and 197:
Guidelines on the
Page 198 and 199:
Guidelines on the
Page 200 and 201:
Guidelines on the
Page 202 and 203:
Guidelines on the
Page 204 and 205:
Guidelines on the
Page 206 and 207:
Guidelines on the
Page 208 and 209:
Guidelines on the
Page 210 and 211:
Guidelines on the
Page 212 and 213:
Guidelines on the
Page 214 and 215:
Guidelines on the
Page 216 and 217:
Guidelines on the
Page 218:
25-27 Middle Gardiner Street Dublin
show all

Guidelines on the Prevention and Control of Tuberculosis in Ireland

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?