Guidelines for chemotherapy of tuberculosis in Taiwan

1
Guidelines for chemotherapy of tuberculosis in
Taiwan

• ?????? ????????
• ???? ??? 2005-3-9

2
Infectious Disease Society of TaiwanThe Society
of Tuberculosis, TaiwanMedical Foundation in
Memory of Dr. Deh-Lin Cheng (J Microbiol
Immunol Infect 200437282-384)

• Foundation of Professor Wei-Chuan Hsieh for
  Infectious Diseases Research and EducationCY
  Lees Research Foundation for Pediatric
  Infectious Diseases and Vaccines

3
Three principles for the guidelines

• 1. From the viewpoint of primary care physician
• 2. Antimicrobial agents recommended already
  marketed in Taiwan
• 3. Base on academic principles rather than the
  regulation of the Bureau of National Health
  Insurance

4
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• New Case

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Pulmonary tuberculosis

• Drugs of choice for New case
• 1. Standard regimen (total 6 months)
• INHRIFEMBPZA for 2 months,
• Then INHRIFEMB for 4 months
• 2. Fixed-dose combinations (total 6 months)
• RifaterEMB for 2 months
• Then RifinahEMB for 4 months
• cavitations on initial chest X ray
• and/or positive cultures at completion of
  initial 2 months treatment,
• ? extend treatment to total 9 months.

6
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• Retreatment

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Pulmonary tuberculosis

• Drugs of choice for
• Retreatment (total 8 months)
• 1. Relapse 2. Default 3. Failure
• INHRIFEMBPZAIA for 3 months,
• Then INHRIFEMB for 5 months
• IA Injectable aminoglycosides include
  streptomycin, kanamycin, and amikacin, and should
  be administered in the initial 2 months of
  treatment

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Retreatment

• 1. Relapse is defined as a patient who develops
  active tuberculosis (by culture, clinical or
  radiological deterioration) after completion of
  anti-tuberculous therapy.
• 2. Default is defined as interruptions in therapy
  of longer than 2 months.
• 3. Failure is defined as continued or recurrent
  positive cultures after 4 months of treatment in
  patients with assured adherence to the prescribed
  anti-tuberculous regimen.

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Pulmonary tuberculosis

• Culture and susceptibility testing should be done
  immediately and regimen should be tailored to
  susceptibility testing results.
• Referral to specialists in Infectious diseases,
  chest medicine or experts on tuberculosis is
  recommended.

10
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• Drugs Resistance
• and Drugs Intolerance

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Drug resistance to INH

• RIFEMBPZA
• for 6 months

• RIFEMBPZA
• IA
• for 6 months

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Drug intolerance to INH

• RIFEMBPZA
• for 6 months

13
Drug resistance to RIF

• INHEMBPZA
• for 9-12 months

• INHEMBPZA
• IA
• /- FQ
• for 9 months
• Fluroquinolones include ofloxacin, ciprofloxacin
  and levofloxacin.

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Drug intolerance to RIF

• INHEMBPZA
• for 9-12 months

• INHEMBPZA
• IA
• /- FQ
• for 9 months
• Fluroquinolones include ofloxacin, ciprofloxacin
  and levofloxacin.

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Drug resistance to EMB

• INHRIFPZA
• for 2 months,
• then
• INHRIF
• for 4 months
• (total 6 months)

• --

16
Drug intolerance to EMB

• INHRIFPZA
• for 2 months,
• then
• INHRIF
• for 4 months
• (total 6 months)

• --

17
Drug resistance to INH, RIF (MDR-TB)

• EMB
• PZA
• IA
• FQ
• TBN (???) (prothionamide)
• for 18-24 months

• --
• Treatment duration is a total of 18 months after
  sputum conversion.

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Drug resistance to INH, RIF, EMB (MDR-TB)

• PZA
• IA
• FQ
• TBN (???) (prothionamide)
• PSA (???)
• for 18-24 months

• --
• Treatment duration is a total of 18 months after
  sputum conversion.

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Drug intolerance to PZA

• INHRIFEMB
• for 9 months

• --

20
Drug intolerance to INH, RIF

• EMB
• PZA
• IA
• FQ
• TBN (???) (prothionamide)
• for 18-24 months

• --
• Treatment duration is a total of 18 months after
  sputum conversion.

21
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• 3 Special situations

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Liver function impairment and/or liver cirrhosis

• RIFEMBPZA
• for 6 months
• Or
• INHRIFEMB
• for 9 months

• RIFEMBIAFQ
• for 12-18 months
• Or
• EMBTBN (???) (prothionamide) IAFQ
• for 18-24 months

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Renal function impairment is defined as
Ccrlt30mL/min or ESRD

• INHRIF
• EMBPZA
• for 2 months
• then
• INHRIF EMB
• for 4 months
• (total 6 months)

• INHRIFEMBPZA
• for 2 months
• then
• INHRIFEMB
• for 4 months
• Intermittent dosing
• (total 6 months)

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Pregnancy or breastfeeding

• INHRIFEMBPZA
• for 2 months
• then
• INHRIFEMB
• for 4 months
• (total 6 months)

• INHRIFEMB
• for 9 months

25
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• Dosage of antituberculous agents
• (for adult only)

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Dosage of antituberculous agents (for adult only)

• INH (100 mg)
• RIF (150 300 mg)
• EMB (400 mg)
• EMB
• PZA (250 mg)
• PZA

• 5 mg/kg BW qd (maximum 300mg)
• 10 mg/kg BW qd (maximum 600mg)
• 15-25 mg/kg BW qd
• 15-25 mg/kg BW qod
• 15-30 mg/kg BW qd (maximum 2 g)
• 12-25 mg/kg BW qd

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Intermittent dosing (3 times weekly) after
hemodialysis

• INH (100mg)
• RIF (150 300 mg)
• EMB (400 mg)
• PZA (250 mg)

• 900mg
• 600mg
• 15-25 mg/kg BW
• 25-35 mg/kg BW

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Dosage of antituberculous agents (for adult only)

• Streptomycin (1g) amikacin (250mg)
• kanamycin (???)
• Ciprofloxacin (250mg)
• Levofloxacin (100mg)
• Ofloxacin (???)

• 15 mg/kg BW qd
• 500-750 mg bid
• 500mg qd
• 400mg bid

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Dosage of antituberculous agents (for adult only)

• TBN (???)
• PAS (???)

• 15-20 mg/kg BW, divided to bid-tid (maximum 1 g)
• 200 mg/kg BW, divided to bid-qid

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Dosage of antituberculous agents (for adult only)

• Rifater
• (INH 80 RIF 120 PZA 250)
• Rifinah-300 (???)
• (INH 150 RIF 300 )
• Rifinah-150 (???)
• (INH 100 RIF 150 )

• 1 tab/10kg BW qd (maximum 5 tab)
• 2 tab qd,
• if BW gt 50 kg BW
• 3 tab qd,
• if BW lt 50 kg BW

31
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• Extrapulmonary tuberculosis

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Pleurisy, Lymphadenitis, Peritonitis (intestinal
disease), Pericarditis, Genito-urinary tract
disease

• INHRIFEMBPZA
• for 2 months
• then
• INHRIFEMB
• for 4 months
• (total 6 months)

• --

33
Bone and joint diseases, pleural empyema

• INHRIFEMBPZA
• for 2 months
• then
• INHRIFEMB
• for 7 months
• (total 9 months)

• --

34
Meningitis, CNS disease

• INHRIFEMBPZA
• for 2 months
• then
• INHRIFEMB
• for 10 months
• (total 12 months)

• --

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Steroids

• Prednisolone lt 1 mg/kg BW qd or equivalent for a
  minimum of 3 weeks
• Recommended in
• Pericarditis
• Meningitis
• CNS disease

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Topics not included

• 1. TB - HIV coinfection
• 2. Drug-drug interaction
• 3. Other antituberculosis drugs (rifabutin,
  cycloserine)
• 4. Treatment of the pediatric population

37
Guidelines for chemotherapy of tuberculosis in
Taiwan(J Microbiol Immunol Infect
200437282-384)

• Thanks for yours attention!