AIT induced hepatitis...

BEFORE STARTING AIT.

Routine baseline liver function test
(LFT) is recommended prior to
starting the standard four-drug
therapy for suspect or active TB
disease. If the tests are normal, no
further tests are required unless
symptoms develop.
I
MONITORING AIT.
If results less than 2X upper limits
and no side effects repeat in one
month. Consult with physician when
greater than 2X upper limit. If any
of LFT > 3X upper limit of normal
{ULN) at any time, consider
stopping therapy and following
protocol.
Do LFTs before you start AIT.
AIT is started if the LFTs are less
than two times normal.

WHEN DO WE CALL A IT- INDUCED

HEPATITIS???
Drug induced hepatotoxicity is
defined as:
****AST/ALT>= 3x ULNwith the
presence of symptoms; OR
****AST/ALT >Sx ULN in the
absence of symptoms; OR
****disproportional increase in
alkaline phosphatase (ALP) and
total bilirubin.

MANAGEMENT.
The management of AIT induced
hepatitis depends upon three
factors ...

1. Subjective condition of patient

2. LFTs
3. Symptomatic/Asymptomatic
WHAT TO DO???
Once AIT induced hepatitis occurs,
STOP ALL DRUGS IMMEDIATELY!!!

Send this labwork

**CBC
**LFTs
**RPM
**Hepatitis A, Band C serology
**Consider any other heptaotoxic
drug or alcohol consumption

Consult with an expert who is

familiar with the management of
hepatotoxicity.
Whether and when to restart the
drugs depends upon the subjective
condition of the patient.

(A) If the patient is stable and

smear negative:
Stop all AIT and no need to start
any other drug therapy. Do LFTs
twice weekly and restart AIT once
the LFTs are less than two times the
upper limit of normal. Restart pro-
tocol is the same as for unstable
and smear positive patients.

(BJ If the patient is unstable and

smear positive:
(If the patient is severely ill with TB
and it is considered unsafe to stop
all AIT)
Stop all ongoing AIT and shift the
patient to SLE ( streptomycin +
levofloxacin + ethambutol)
Continue serial monitoring of LFTs
twice weekly. The first line AIT
drugs will be restarted once ALT is
less than two times the upper limit
of normal.
RESTART PROTOCOL/
RECHALLENGING AIT.
Once LFTs are less than twice the
upper limit of normal... introduce
primary AIT in the sequence of RIP
(rest in peace...Rifampicin then
/soniazid then Pyranazimide).

1. Continue checking LFT. If LFT

<2x ULN, re-challenge first with
Rifampin because of its efficacy
and is least likely to cause
hepatotoxicity.
2. If LFT does not increase after 1
week, then /NH should be added to
the regimen.
3. Pyrazinamide (PZA) can be
added next (1 week after /NH) if
LFT does not increase.

Drugs are added in a manner that

initially half of dose is introduced
for 3 days and if the patient
tolerates only then full blown dose
of the drug is given with monitoring
of LFTs. There should be a gap of
at least one week between two
rechallenged AIT drugs.
Important point
If at any time of re-challenged
period, symptoms recur or AST
increases, the last drug added
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