PRESENTER:

ALAN NA
5TH YEAR 2ND SEMESTER
TREATMENT OBJECTIVES
1. TO CURE THE PATIENT AND TO RESTORE
THE QUALITY OF LIFE & PRODUCTIVITY.
2. TO PREVENT DEATH FROM ACTIVE TB OR
ITS LATE EFFECTS.

3. TO PREVENT RELAPSE OF TB.

4. TO REDUCE THE TRANSMISSION OF TB TO
OTHERS.
5. TO PREVENT DEVELOPMENT AND
TRANSMISSION OF DRUG RESISTANCE.
DOTS STRATEGY
DIRECTLY OBSERVED TREATMENT, SHORT-COURSE

1. GOVERNMENT COMMITMENT TO A NATIONAL

TUBERCULOSIS CONTROL PROGRAMME.
2. CASE DETECTION THROUGH SPUTUM SMEAR
MICROSCOPY EXAMINATION OF TUBERCULOSIS
HEALTH SUSPECTS IN GENERAL HEALTH SERVICES
3. A STANDARDIZED SHORT-COURSE TUBERCULOSIS
TREATMENT REGIMEN OF 6 MONTHS UNDER
DIRECT OBSERVATION OF A TRAINED SUPERVISOR
TO ENSURE PATIENT TAKES EVERY DOSE OF
MEDICATION.
4. A REGULAR UNINTERRUPTED SUPPLY OF QUALTY
ANTI-TUBERCULOSIS DRUGS.
5. A MONITORING AND REPORTING SYSTEM TO
EVALUATE TREATMENT OUTCOME FOR EACH AND
EVERY PATIENT WITH PROPER DOCUMENTATION.
ADVANTAGES OF DOTS
 CURE RATES OF UP TO 95% EVEN IN
POOREST COUNTRIES.
 CASE DETECTION BY SPUTUM
MICROSCOPY IS CHEAP, RELIABLE AND
SIMPLE.
 ISOLATION OR HOSPITALIZATION IS NOT
REQUIRED.
 TRAINED HEALTH WORKERS OR
COMMUNITY VOULUNTEERS CAN
SUPERVISE TREATMENT.
 HELPS TO PREVENT DRUG RESISTANCE.
MEDICATIONS
TREATMENT DURATION:
6 MONTHS

DRUGS CAN BE CLASSIFIED INTO:

 1ST LINE DRUGS
 2ND LINE DRUGS
 NEWER DRUGS
FIRST LINE DRUGS (5)
 RIFAMPIN (R)
 ISONIAZID (H)
 PYRAZINAMIDE (Z)
 ETHAMBUTOL (E)
 *STREPTOMYCIN (S)
RIFAMPIN (R)
Most important and potent antituberculous agent.

M/A
• Bactericidal activity (Intracellular and Extracellular)
• Inhibits RNA Synthesis.

S/E (OHCS, 7TH EDITION)

• Hepatitis (Monitor AST and Bilirubin)
• Orange discoloration of bodily fluids; urine, tears.
• Inactivation of the Pill.
• Flu-like syndrome with intermittent use.
ISONIAZID (H)
Best antituberculous drug currently after
Rifampin.

M/A
• Inhibition of cell wall synthesis.
• Bacteriostatic & bactericidal effect.

S/E (OHCS, 7TH EDITION)

• Hepatitis
• Neuropathy
• Pyridoxine deficit
• Agranulocytosis
PYRAZINAMIDE (Z)
Important bactericidal drug in short-course
therapy for tuberculosis.

M/A
Narrow spectrum activity.
Bactericidal effect
A prodrug – converted by the tubercle bacillus
to the active form – pyrazinoic acid.

S/E (OHCS, 7TH EDITION)

Hepatitis
Arthralgia (CI: Acute gout, porphyria)
ETHAMBUTOL (E)

M/A
• Bacteriostatic effect.
• Inhibit arabinosyltransferase that mediates
polymerisation of arabinose into
arabinogalactan in cell wall synthesis.

S/E (OHCS, 7TH EDITION)

Optic neuritis (Color vision deteriorates)
STREPTOMYCIN (S)
Least used in the US due to it’s toxicity.
Available only in intramuscular and
intravascular forms.

M/A
• Inhibits protein synthesis by disrupting
ribosomal function.

S/E
• Ototoxicity (hearing loss, vestibular
dysfunction)
• Nephrotoxicity ( Renal failure)
TREATMENT CATEGORIES
 CATEGORY I – NEW CASE.
 CATEGORY II – RELAPSE,
TREATMENT FAILURE, TREATMENT
AFTER INTERRUPTION.
 CATEGORY III – CHRONIC CASE.
TREATMENT REGIMEN
TREATMENT CONSISTS OF 2 PHASES:
1. INITIAL OR INTENSIVE PHASE (2 MONTHS)
2. CONTINUATION OR MAINTENANCE PHASE
(4 MONTHS)

CATEGORY I – NEW CASE

2HRZE/4HR
GIVE PYRIDOXINE THROUGHOUT
TREATMENT.
- OHCS, 7TH EDITION

WHY?
ISONIAZIDE CAUSES INTERRUPTION TO PYRIDOXINE
METABOLISM.

PYRIDOXINE (VITAMIN B6) IS AN IMPORTANT

NEUROPROTECTOR.

DEFICIENCY OF PYRIDOXINE LEADS TO NERVE

ASSOCIATED PROBLEMS, E.G PERIPHERAL
NEUROPATHY.

INITIAL MANIFESTATION: NUMBNESS OF THE

EXTREMITIES
2ND LINE DRUGS
Used either when tuberculosis drug is resistant or when first-line
supplemental drugs are not available.
Drugs are arrange according to the order (descending) usefulness.
1. QUINOLONES
2. CAPREOMYCIN
3. RIFABUTIN
4. AMIKACIN
5. ETHIONAMIDE
6. PARA-AMINOSALICYLIC ACID (PAS)
7. CYCLOSERINE
-ADOPTED FROM HARRISONS PRINCIPLES OF INTERNAL MEDICINE,

16TH EDITION
NEWER DRUGS
 SQ-109
 NITROIMIDAZOLES
 DIARYLQUINOLINE
 PYRROLES
 OXAZOLIDINONES
 MACROLIDES
NEWER THERAPIES
ADOPTED FROM PRACTICE GUIDELINES FOR CONTROL AND MANAGEMENT OF
TUBERCULOSIS MINISTRY OF HEALTH, MALAYSIA ( 2 ND EDITION 2002)
References
1. Harrison’s Principles of Internal Medicine, 16th
Edition.
2. Malaysian Practice Guidelines of Control and
Management of Tuberculosis, 2nd Edition, 2002,
MOH Malaysia.
3. Oxford Handbook of Clinical Medicine, 7th Edition.
4. WHO Official website – http://who.int
5. Directly observed therapy (DOT) for tuberculosis:
why, when, how and if? – L. Peter Ormerod,
Thorax 1999.