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Management of DR-TB: PMDT Guideline
Management of DR-TB: PMDT Guideline
Management of DR-TB: PMDT Guideline
PMDT Guideline
Dr Subhankar Roy, Junior Resident, Department of Medicine, IPGME&R
Chairpersons- Dr Avas Chandra Ray, Associate Prof, Dept of Medicine, IPGME&R
Dr Amitabha Sengupta, Professor, Dept of Pulmonary Medicine, IPGME&R
Few Terminologies
Group A- Group C-
Levofloxacin/Moxifloxacin Delamanid
Bedaquiline Amikacin/Streptomycin
Linezolid Pyrazinamide
Group B- Ethionamide/Prothionamide
Clofazimine PAS
Cycloserine/Terizidone Ethambutol
Imipenem-Cilastatin/Meropenem
Pre-Treatment Counselling
Information
on lab
result
Importance
TPT of early
initiation
Nature &
Family
duration of
planning Pre- treatment
Treatment
Counselling
Infection Possible
control change in
precaution treatment
Care and
Reassurance
support
to family
services
Treatment of MDR/RR-TB
Initial phase (IP): 4 months which can be extended up to 6months, Bdq is used
for 1st 6 months.
Continuation phase (CP): 5months
Total Duration: 9-11 months
IP: (4-6) Mfxh, Km/Am, Eto, Cfz, Z, Hh, E CP: (5) Mfxh, Cfz, Z, E
1. XDR-TB patients
2. MDR/RR-TB patients who are excluded from shorter oral Bdq containing regimen
3. Additional resistance or intolerance or non-availability of any drug in use or
emergence of exclusion criteria
4. Return after LTFU
5. Failure of shorter oral Bdq containing regimen
6. MDR-TB in pregnant patients who are unwilling for MTP
Treatment Extension
If month 5 or 4 culture result is positive, dose of Lzd (600mg) & the regimen
to be extended by 1month to month 7 ( for a maximum of 8months)
If month 8 culture is positive, FL-LPA, SL-LPA & culture-DST to be done
Duration of Pregnancy
PTE:
1. History & physical examination
2. Height/Weight
3. RBS
4. CXR
5. HIV test
Treatment Regimen: ( 6 or 9) Lfx R E Z
In exceptional cases due to unavailability of loose drug, use of 4FDC (HRZE)
with Lfx loose tablets may be considered rather than not starting treatment
Replacement sequence
Regimen Dose
6Lfx for contacts of R resistant FQ 1.Age>14yr
sensitive patients BW<45kg- 750mg/day
BW>45kg- 1000mg/day
2. Age<14yr 15-20mg/kg/day
4R for contacts of H resistant R Age >10yrs- 10mg/kg/day (Max 600mg)
sensitive patients Age <10yrs- 15mg/kg/day
6H can be used for RR-TB with FQ & H sensitive patients
Management of adverse drug reaction
QTcF Prolongation
Normal M<450 ms, F<470 ms
Culprit drugs- Bdq, FQ, Cfz, Dlm
Nephrotoxicity-
Culprit drug- SLI
Discontinue suspected agent
Restart the drug @2-3 times/wk if the drug is essential to the regimen
Adjust all TB drugs according to CrCl
Hearing loss-
Culprit Drug- Aminoglycosides
If early symptoms- reduce the dose twice/thrice per week
Hearing threshold >40 dB <8000 Hz- Stop Aminoglycoside
Optic neuritis-
Culprit Drug- E, Lzd, Eto, Cfz, H, S
STOP E & LZD, Do not restart
Usually reverses with cessation of drug
Hepatotoxicity
Culprit Drugs- Z, H, R, Eto, PAS, Bdq
If the patient is very sick (Meningitis, smear 3+), then administer ATT
For not so serious patients, introduction of ATT can be delayed
Rule out other potential causes of hepatitis ( Viral hepatitis, alcohol induced, other
medications)
AST/ALT >5*UNL with normal Bil OR
AST/ALT <5 *UNL with normal
AST/ALT >3*UNL with Bil>2*UNL OR
Bil & Asymptomatic patient
Symptomatic patient
Improvement No Improvement