medication for tuberculosis

MEDICATION (DRUGS)
First Line
• Regimen 1 (preferred)
- Initial phase: Isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) once daily for 8 weeks
- Continuation phase: INH/RIF daily for 18 weeks. Or INH/RIF twice weekly for 18 weeks (only use for HIV+ if CD4>100) Or INH/ Rifapentine once weekly for 18 weeks (acceptable alternative for HIV- patients only) (1)[A]
• Regimen 2
- Initial phase: INH/RIF/PZA/EMB daily for 2 weeks, then twice weekly for 6 weeks
- Continuation phase: INH/RIF twice weekly for 18 wks (HIV+ patients only if CD4>100) or INH/Rifapentine once weekly for 18 weeks (acceptable alternative for HIV- patients only) (1)[A]
• Regimen 3 (acceptable alternative)
- Initial phase: INH/RIF/PZA/EMB daily for 8 weeks
- Continuation phase: INH/RIF 3 times weekly for 18 weeks (1)[A]
• Regimen 4 (only when unable to give preferred regimen)
- Initial phase: INH/RIF/EMB daily for 8 weeks
- Continuation phase: INH/RIF daily or twice weekly for 31 weeks (1)[B]
- No studies proving efficacy of 5 times weekly regimen, but clinical evidence suggests it. [C] Directly observed therapy required for nondaily regimens. (1)
• Latent tuberculosis should be treated with Isoniazid 300 mg/d for adults, and 10-15 mg/kg (not to exceed 300 mg/d) in children for 6-12 months with DOT. Dosing
• INH: Scored tabs 50/100/300 mg, syrup 10 mg/mL, or aqueous solution 100 mg/mL
- Daily dose: Adult 5 mg/kg (max 300 mg); pediatric 10-15 mg/kg (max 300 mg)
- 3 times weekly: Adult 15 mg/kg (max 900 mg)
- Twice weekly: Adult 15 mg/kg, (max 900 mg); pediatric 20-30 mg/kg (max 900 mg)
- Weekly: Adult only, 15 mg/kg (max 900 mg);
- Consider pyridoxine 10-50 mg/d
• RIF: Capsules 150/300 mg, powder for oral suspension, or IV aqueous
- Daily or twice weekly dose: Adult and pediatric 10-20 mg/kg (maximum 600 mg)
• PZA: Scored tabs 500 mg. Dosed by weight
- Adults 40-55 kg
 Daily: 18-25 mg/kg, max 1 g
 3 times weekly: 27-37 mg/kg, max 1.5 g
 Twice weekly: 36-50 mg/kg, max 2 g
- Adults 56-75 kg
 Daily: 20-27 mg/kg, max 1.5 g
 3 times weekly: 33-45 mg/kg, max 2.5 g
 Twice weekly: 40-54 mg/kg, max 3 g
- Adults >75 kg
 Daily: 22-26 mg/kg, max 2 g
 3 times weekly: 33-40 mg/kg, max 3 g
 Twice weekly: 44-53 mg/kg, max 4 g
- Pediatric daily: 15-30 mg/kg (maximum 2 g)
- Pediatric twice weekly: 50 mg/kg (maximum 4 g)
• Rifabutin (Mycobutin): Capsules 150 mg
- Daily or twice weekly: Adult 5 mg/kg, max 300 mg
• Rifapentine (Priftine): Tablet 150 mg; for continuation phase only
- HIV- adults: 600 mg once weekly, given with INH. Not effective if HIV+. (1)[A]
• EMB: Tablets 100/400 mg bacteriostatic. Dose based on weight.
- Adults 40-55 kg
 Daily: 15-20 mg/kg, max 800 mg
 3 times weekly: 22-30 mg/kg, max 1.2 g
 Twice weekly: 36-50 mg/kg, max 2 g
- Adults 56-75 kg
 Daily: 16-22 mg/kg, max 1.2 g
 3 times weekly: 27-36 mg/kg, max 2 g
 Twice weekly: 37-50 mg/kg, max 2.8 g
- Adults >75 kg
 Daily: 22-26 mg/kg, max 2.6 g
 3 times weekly: 33-40 mg/kg, max 2.4 g
 Twice weekly: 44-53 mg/kg, max 4 g
- Pediatrics
 Daily: 15-20 mg/kg, max 1 g
 Twice weekly: 50 mg/kg, max 4 g
• Contraindications
- RIF: Avoid if patient taking antiretrovirals
- EMB: May cause optic neuritis. Avoid unless patient old enough to cooperate for visual acuity and color testing
• Precautions
- INH, RIF, PZA: May cause hepatitis. Caution if liver disease.
- RIF: Colors urine, tears, and secretions orange. Can stain contact lenses.
- INH: Peripheral neuritis and hypersensitivity possible. Treat with pyridoxine.
- PZA: May increase uric acid. Unclear safety during pregnancy [C]
• Significant possible interactions: Rifamycins alter level of phenytoin, antivirals, and other drugs metabolized by liver and may inactivate birth control pills (recommend a barrier method).
Second Line
• Steroids: Use only with concurrent anti-TB therapy. Recommended for TB meningitis or pericarditis. (3)[B]
• Streptomycin: Cautionototoxic and nephrotoxic; do not use in pregnancy.