TB Treatment in patients with liver disorders

Isoniazid, rifampicin and pyrazinamide are all associated with hepatitis. Of the three medications,
rifampicin is least likely to cause hepatocellular damage, although it is associated with cholestatic
jaundice; pyrazinamide is the most hepatotoxic. Patients with the following conditions can receive the
usual short-course chemotherapy regimen provided that there is no clinical evidence of chronic liver
disease: hepatitis virus carriage, a past history of acute hepatitis, excessive alcohol consumption.
However, hepatotoxic reactions to TB medications may be more common in these patients and
should be anticipated.
Patients with liver disease should not receive pyrazinamide. Isoniazid plus rifampicin plus one or two
non-hepatoxic drugs such as streptomycin and ethambutol can be used for total treatment for duration
of 8 months. Alternative regimens are 9 RE or SHE in the initial phase followed by HE in the
continuation phase, with a total treatment duration of 12 months. Therefore, recommended regimens
are 2 SHRE/ 6HR or 9RE or 2 SHE / 10HE.
In case of acute hepatitis, which may or may not be related to TB or TB treatment, the medical
officer’s clinical judgment is required. In some cases, TB treatment may be deferred until acute
hepatitis has resolved. When the clinician/ Physician decides to treat TB during acute hepatitis, the
combination of SE for 3 months is the safest option. If the hepatitis has resolved, the patient can
receive a continuation phase of 6 months of RH. If the hepatitis fails to resolve, SE should be
continued for a total of 12 months.
Expert consultation is advised in treating patients with advanced or unstable liver disease in
conjunction with clinical and laboratory monitoring.
Abdominal TB:
TB may affect different parts of the gastrointestinal tract down to the rectum and anus. Abdominal TB
may be acute or chronic, and patients often present with fever, weight loss, abdominal pains, and
distension with diarrhoea or constipation. Abdominal TB accounts for about 3% of all the cases of TB,
and 12% of the EPTB cases. Diagnosis is often difficult due to nonspecific symptoms, but
histopathology examination of specimen collected from affected area can assist with diagnosis.

Summary of Investigations for EPTB (Extra Pulmonary TB/ TB outside of the lungs
Anatomical site Recommended investigations

TB adenitis (especially from cervical region) Lymph node biopsy or fine needle aspiration; sputum if
coughing
Miliary TB Sputum and chest x-ray. Perform additional diagnostic tests
as appropriate for associated symptoms and signs (i.e.,
lumbar puncture to test for meningitis).
TB meningitis Lumbar puncture (CSF for white blood cell count with
differential; biochemical analysis for protein and glucose
concentration, AFB smear and mycobacterial culture); chest
x-ray and sputum
Pleural effusion Chest x-ray, pleural tap for biochemical analysis (protein
and glucose concentration, white blood cell count, AFB
smear and mycobacterial culture), sputum
Abdominal TB Abdominal ultrasound and ascitic tap for white blood cell
count total and differential; biochemical analysis for protein
and glucose concentration, AFB smear and mycobacterial
culture; sputum and chest x-ray if coughing
TB of spine/bones/joints (osteoarticular TB) X-ray, joint tap for white blood cell count total and
differential; biochemical analysis for protein and glucose
concentration, AFB smear and mycobacterial culture;
synovial biopsy; sputum if coughing
Pericardial TB Chest x-ray, chest ultrasound, pericardial tap for white blood
cell count total and differential; biochemical analysis for
protein and glucose concentration, AFB smear and
mycobacterial culture; sputum if coughing
Reference: Lesotho National Guidelines for Tuberculosis, 2013 Edition. Current
edition not yet published. this is still outstanding