Clinical Manual for Management of the HIV-Infected ... - myCME.com

Table 1. World Health Organization’s Recommended
First-Line Regimens for Tuberculosis Treatment
TB
Category
TB Patients TB Treatment Regimens
I New smear
positive; new
smear negative
with extensive
chest x-ray
abnormalities,
severe HIV
disease, or severe
extrapulmonary
TB
II Previously
treated
smear-positive
pulmonary TB #
•
•
•
relapse
return after
default
treatment
failure
III Smear-negative
TB and
extrapulmonary
TB less severe
than
category 1 ##
IV Chronic and
multidrugresistant
TB
(smear positive
after supervised
retreatment)
Initial Phase
(daily or 3
times weekly)
Isoniazid, *
rifampin, **
pyrazinamide,
ethambutol ***
for 2 months
Isoniazid, *
rifampin, **
pyrazinamide,
ethambutol and
streptomycin
for 2 months,
followed by
isoniazid, *
rifampin, **
pyrazinamide
and ethambutol
for 1 month
Isoniazid, *
rifampin, **
pyrazinamide,
ethambutol for 2
months
Continuation
Phase
(daily or 3
times weekly)
Isoniazid * and
rifampin ** for 4
months
Isoniazid and
ethambutol †
daily for 6
months
Isoniazid, *
rifampin, ** and
ethambutol for 5
months
Isoniazid * and
rifampin ** for 2
months
Isoniazid * and
ethambutol †
daily for 6
months
Multidrug-resistant or individualized
regimen per country protocol
Source: Harries A, Maher D, Graham S. TB/HIV: A Clinical Manual, second edition. 2004. WHO, Geneva.
* Pyridoxine 10 mg daily is added to each dose of isoniazid.
** Rifampin is called rifampicin in other countries. It is recommended that every rifampin dose be
supervised (directly observed therapy). Rifampin should not be used with nevirapine or protease
inhibitors; rifabutin may be substituted with appropriate dosage adjustments.
*** In TB meningitis, the World Health Organization recommends substituting streptomycin for
ethambutol.
† Isoniazid and ethambutol is expected to have a higher failure rate than isoniazid and rifampin;
however, it is included for treatment when continuation-phase therapy cannot be directly supervised, to
avoid the risk of promoting resistance to rifampin.
# Culture and susceptibility testing (if available) should be performed at the beginning of Category II
treatment.
## HIV-infected patients in Category III will take the same treatment as persons in Category I.
Pregnancy
Section 6—Disease-Specific Treatment | 6–77
The WHO considers all Category I medications to be
safe in pregnancy. Avoid streptomycin (Category II
treatment) if possible, as it can cause 8th cranial nerve
damage to the fetus.
Breastfeeding
The WHO considers all anti-TB medications to be safe
during breast-feeding.
Hepatic Disease
Pyrazinamide should be avoided in patients with
preexisting liver disease. For mild-to-moderate liver
disease, an initial 2-month regimen of isoniazid,
rifampin, ethambutol, and streptomycin can be followed
by a 6-month course of isoniazid and rifampin. For
severe liver disease, 2 months of isoniazid, ethambutol,
and streptomycin is followed by 10 months of isoniazid
and ethambutol. If these regimens are not tolerated, or
if drug resistance is suspected, consult an expert.
Renal Disease
Ethambutol should be dose-adjusted or avoided
altogether in severe renal insufficiency. Streptomycin
doses must be adjusted in patients with abnormal renal
function.
Polydrug or Multidrug Resistance
Patients with polydrug or multidrug resistance may
be treated with standardized Category IV regimens
or individualized regimens, depending on the country
protocol. Category IV patients should be treated
according to expert advice or in specialized centers.