Interventions for Tuberculosis Control and Elimination 2002

The patient with acute renal toxicity
Acute renal toxicity may be the result of a hemolytic anemia, glomerulonephritis
and interstitial nephritis. The most likely cause of this rare
adverse drug event is rifampicin. The drug should be withdrawn and never
be given again. If renal insufficiency has developed, the dosages of ethambutol
and streptomycin must be reduced according to the remaining function
as these drugs are almost entirely excreted through the kidneys.
The patient with osteo-articular pain
Arthralgia is a frequent adverse drug event resulting from accumulation of
uric acid due to pyrazinamide. In many instances, the dosage of pyrazinamide
is higher than that recommended in patients who have such reactions
and, if so, should be reduced to within the recommended limits. It
often occurs towards the end of the intensive phase, when pyrazinamide
can be withdrawn without replacement. Alternatively, acetyl salicylic acid
commonly alleviates the symptoms. Intermittent administration of pyrazinamide
will also reduce the effect of uric acid retention. Allopurinol is
ineffective.
The approach to the patient
with pre-existing medical conditions
Patients may present not only with tuberculosis but also other medical conditions
that require modifications of the standard treatment. In this chapter,
some of the major medical conditions that require such adjustments are
discussed.
The patient with liver injury
Patients with mild and clinically unrecognizable liver injury, including those
who abuse alcohol, may be treated with the standard treatment, which needs
to be adjusted only if clinical signs of hepatitis occur as discussed in the
previous chapter.
Patients presenting with clinical signs of hepatitis should not be given
the drugs with the greatest potential for hepatotoxic reactions. These include
isoniazid, rifampicin, and pyrazinamide. Such a patient might be treated
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