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Management of Adverse Effects of Anti-TB drugs (part I). Dr. Ashraf Abdulhaseeb Chest Diseases Consultant Chief of DR-TB center, Abbassia Chest Hospital. Presentation outline : Monitoring adverse effects Main adverse effects and suspected drugs.
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Management of Adverse Effects of Anti-TB drugs (part I) Dr. Ashraf Abdulhaseeb Chest Diseases Consultant Chief of DR-TB center, Abbassia Chest Hospital
Presentation outline: • Monitoring adverse effects • Main adverse effects and suspected drugs. • General considerations of adverse effects management. • Commonly used ancillary drugs.
Monitoring of adverse effects: Aims at: • Early detect and treat adverse effects • Prevent /minimize toxic effects or organ damage
Monitoring should consider the following factors: • Patient factors: • Age, • initialclinical condition, • HIV testing, • Socioeconomic condition • Providers: • trained and alert to early detect adverse effects • Specialists and consultants in referral centers are available.
Monitoring schedule I) Initial pretreatment screening and evaluation: • Initial evaluation serves to: • Establish a baseline clinical view of the patient • identify patients who are at increased risk for adverse effects or poor outcomes.
Initial pretreatment monitoring includes: • Thorough medical history and physical examination. • History of concomitant conditions which can contribute occurrence of drug intolerance • History of adverse drug reactions. • History of allergic reactions • Complete blood count • Liver functions: • Total serum Bilirubin • SGPT & SGOT • Total serum albumin, total serum protein and A/G ratio.
Serum Creatinine, blood urea, complete urine analysis with estimation of total urine protein content • Serum uric acid. • Fasting and PP blood sugar. • Pregnancy test. • Initial chest x-ray • Visual acuity, color vision • Audiometry • Direct smear examination • DST for first and second line anti-TB drugs.
II) Lab investigation schedule during treatment to monitor adverse effects
II) Lab investigation schedule during treatment to monitor adverse effects, cont.
Monitoring of adverse effects should also include: • In high risk patients (over 50 years, renal insufficiency, DM, HIV, underweight), creatinine should be evaluated every week or every other week for at least the first month of treatment. • Creatinine clearance may be needed for high risk group patients. • If Serum potassium is low, check the Magnesium and Calcium levels.
Special attention should be paid for: • Liver toxicity. • Vestibular and hearing toxicity with injectable drugs. • Psychiatric disorders with Cycloserine. • Allergic reactions. • Hematological changes.
Recording the adverse effects in patient file: Patient name__________________________________ Patient ID____________________ TB registrations number ___________________________________________________ Severity code: *1=asymptomatic 2=does not affect daily activities 3=limits daily activities 4=life threatening hospitalization Outcome code: **1= complete resolution 2= partial resolution 3 = no change 4 = worse comments:_______________________________________________________________
Classification of Adverse Effects Allergic and dermatological:
Classification of Adverse Effects Gastrointestinal:
Classification of Adverse Effects Neurological and Psychiatric:
Classification of Adverse Effects Fluid and electrolyte disturbance &others:
Classification of Adverse Effects Endocrine adverse effects:
Management of adverse effects General considerations: • majority of adverse effects are easy to recognize. • have a systematic method of patient interviewing to early detect. • Proper management of adverse effects begins with patient education. Inform the patient to report adverse effects. • Monthly evaluation by a physician during ambulatory treatment
General considerations, cont. • DOT workers should be trained to screen patients for adverse effects. • Scheduled laboratory screening to detect occult adverse effects e.g. nephrotoxicity. • Electrolyte disturbance is generally a late effect occurring after months of starting treatment. • Complete discontinuation of therapy because of adverse effects is rare.
General considerations, cont. • Mild adverse effect is or not dangerous, continue the treatment regimen, with the help of ancillary drugs if needed. • Some adverse effects may disappear or diminish with time, and patients may be able to continue receiving the drug if sufficiently motivated. • adverse effects of a number of second-line drugs are highly dose dependent, reducing the dosage of the offending drug is another method of managing adverse effects
General considerations, cont. • Pyridoxine (vitamin B6) should be given to all patients receiving cycloserine or terizidone to help prevent neurological adverse effects. Recommended dose is dose is 50 mg for every 250 mg of cycloserine • Psychosocial support is an important component of the management of adverse effects.
General considerations, cont. • Psychosocial support is an important component of the management of adverse effects. A stock of these drugs should be always available. • Timely and intensive monitoring for, and management of, adverse effects caused by second-line drugs are essential components of DR-TB control program.
