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/HPSCTable 5.2. Dosages for primary medications used in the treatment of tuberculosisDrugMode of actionRoute ofadministrationDaily dose[max]3 Times aweekdose [max]2 Times aweekdose [max]Major adversereactions*IsoniazidBactericidalOral/IntramuscularChildren:5-10mg/kg 1Adults: 5mg/kg [300mg]Children:20mg/kgAdults:10mg/kg(range8-12mg/kg)[900mg]Children: 20mg/kgAdults: 15mg/kg(range 13-17mg/kg)[900mg]Hepatic enzymeelevations, hepatitis,rash, peripheralneuropathy, CNSeffects, increasedphenytoin levels,possible interactionwith disulfiramRifampicinBactericidalOral/IntravenousChildren: 10-20mg/kg 2Adults: 600mg(range8-12mg/kg)[600mg]Children: 10-20mg/kgAdults:600mg(range8-12mg/kg)[600mg]Children: 10-20mg/kgAdults: 600mg(range 8-12mg/kg)[600mg]Hepatic enzymeelevations, hepatitis,rash, fever,thrombocytopaenia,influenza-like syndrome,reduced levels ofmany drugs (includingmethadone, warfarin,hormonal forms ofcontraception, oralhypoglycaemic agents,theophylline, dapsone,ketoconazole, PIs, andNNRTIs)PyrazinamideBacteriostaticOralChildren:25mg/kg(range 20-30mg/kg)Adults: 25mg/kg (range 20-30mg/kg)[2.0g foradults andchildrenChildren:35mg/kg(range 30-40mg/kg)Adults:35mg/kg(range 30-40mg/kg)[3.0g foradults andchildrenChildren: 50mg/kg(range 40-60mg/kg)Adults: 50mg/kg(range 40-60mg/kg)[3.5g for adultsand childrenGastrointestinal (GI)upset, hepatotoxicity,hyperuricaemia, gout(rarely), arthalgias, rashEthambutolBacteriostaticOralChildren:20mg/kg(range 15-25mg/kg)[1.5g]Adults: 15-25mg/kg[2.0g]Children:30mg/kg(range 25-35mg/kg)Adults:30mg/kg(range 25-35mg/kg)[2.8g]Children: 40-50mg/kg[2.5g]Adults: 45mg/kg(range 40-50mg/kg)[3.6g]Decreased red-greencolour discrimination,decreased visual acuity,skin rashStreptomycinBactericidalIntramuscular/IntravenousChildren:15-30mg/kgAdults: 15mg/kg [1.0g]Children:15mg/kgAdults:15mg/kg[1.0g]Children: 15mg/kgAdults: 15mg/kg[1.0g]Auditory toxicity, renaltoxicity, hypokalaemia,hypomagnesaemia*All toxicities are not listed here. Full prescribing information should be checked in the package insert or pharmacology texts.-67-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCTable 5.2. Contd.DrugRecommended regularmonitoringCommentsIsoniazid- Monthly clinical- Vitamin B 6(pyridoxine) 10mg/day may decrease peripheral neuritisevaluationand CNS effects and should be used in patients who are abusing- Liver function tests 3 alcohol, pregnant, breastfeeding infants on isoniazid, malnourished,or who have HIV infection, cancer, chronic renal or liver disease,diabetes, or pre-existing peripheral neuropathy- Aluminium-containing antacids reduce absorption- Drug interactions with several agentsRifampicinPyrazinamideEthambutolStreptomycin- Monthly clinicalevaluation- Complete blood cellcount including plateletsand liver function testsas indicated 3- Monthly clinicalevaluation- Liver function tests asindicated 3- Monthly clinicalevaluation- Check colour vision andvisual acuity monthly- Monthly clinicalevaluation- Audiometry, renalfunction, electrolytes,including magnesium- Orange discolouration may occur in contact lenses and bodysecretions such as tears and urine- Patients receiving methadone will need their methadone dosageincreased, by an average of 50%, to avoid opioid withdrawal- Interaction with many drugs leads to decreased levels of the coadministereddrug- May make glucose control more difficult in people with diabetes.- Contraindicated for patients taking most PIs and NNRTIs- Patients should be advised to use barrier contraceptives while onrifampicin- May complicate management of diabetes mellitus- Hyperuricaemia can be used as indicator of compliance- Treat increased uric acid only if symptomatic- Allopurinol increases level of pyrazinamide by inhibiting xanthineoxidase resulting in failure of allopurinol to lower serum uric acid- Optic neuritis may be unilateral; check each eye separately. Ifpossible avoid in children too young to undergo vision testing.- If patient develops visual complaints, refer for promptophthalmologic evaluation. May need to discontinue ethambutolwhile awaiting evaluation.- Ultrasound and warm compresses to injection site may reduce painand induration1World Health Organization (WHO), International Union against TB and Lung Disease (IUATLD), and British Thoracic Society (BTS)recommend 5mg/kg in children; Centers for Disease Control and Prevention (CDC), American Thoracic Society (ATS), InfectiousDisease Society of America (IDSA) and the American Academy of Paediatrics (AAP) recommend 10-20mg/kg2WHO, IUATLD, and BTS recommend 10mg/kg in children; CDC/ATS and the AAP recommend 10-20mg/kg3Liver function tests are indicated if baseline is abnormal or patient has risk factors for toxicityReproduced with kind permission from Tuberculosis, Clinical Policies and Protocols. New York City Department of Health and MentalHygiene (2008). Available at www.nyc.gov/html/doh/downloads/pdf/tb/tb-protocol.pdfRecommendation:To enhance compliance and to minimise potential problems from the development of drugresistance, it is strongly recommended that only combination tablets should be used.Syrup/tablet dosage should be rounded up or down to facilitate the prescription of easily given volumes/tablets. All cases of TB placed on the above regimens for active disease should be notified to the localpublic health physicians. In addition, the committee recommends routine audit of both inpatient andoutpatient care of TB.Care should be taken in writing prescriptions so that rifadin (contains rifampicin only) is not confused withrifinah (contains rifampicin and isoniazid) and rifater (contains rifampicin, isoniazid and pyrazinamide).-68-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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