Management of tuberculosis refers to techniques and procedures utilized for treating tuberculosis (TB), or simply a treatment plan for TB. The medical standard for active TB is a short course treatment involving a combination of isoniazid, rifampicin (also known as Rifampin), pyrazinamide, and ethambutol for the first two months. During this initial period, Isoniazid is taken alongside pyridoxal phosphate to obviate peripheral neuropathy. Isoniazid is then taken concurrently with rifampicin for the remaining four months of treatment (6-8 months for miliary tuberculosis). A patient is expected to be free from all living TB bacteria after six months of therapy in Pulmonary TB or 8-10 months in Miliary TB. Latent tuberculosis or latent tuberculosis infection (LTBI) is treated with three to nine months of isoniazid alone. This long-term treatment often risks the development of hepatotoxicity. A combination of isoniazid plus rifampicin for a period of three to four months is shown to be an equally effective method for treating LTBI, while mitigating risks to hepatotoxicity. Treatment of LTBI is essential in preventing the spread of active TB.
Drugs
First line All first-line anti-tuberculous drug names have semi-standardized three-letter and single-letter abbreviations:
ethambutol is EMB or E isoniazid is INH or H pyrazinamide is PZA or Z rifampicin is RMP or R streptomycin is SM or S First-line anti-tuberculous drug names are often remembered with the mnemonic "RIPE", referring to the use of rifamycin (like rifampin), isoniazid, pyrazinamide, and ethambutol. In US practice, names and abbreviations that are not universally accepted are used. For example, rifampicin is referred to as rifampin and is abbreviated as RIF, while streptomycin is referred to as STM. The notations RIF, RFP, and RMP have all been frequently used for rifampicin, and the notations IRPE, HRZE, RIPE, and IREP for combination regimens are all synonyms or nearly synonyms depending on dosage schedules. Other abbreviations have also been widely used). In this system, which the World Health Organization (WHO) supports, "RIPE" is "RHZE". (Both have mnemonic potential, as tuberculosis is named after tubercles (small tubers), and a tuber can be ripe and can be a rhizome.) This regimen is also known as "HREZ". Drug regimens are similarly abbreviated in a semi standardized manner. The drugs are listed using their single letter abbreviations (in the order given above, which is roughly the order of introduction into clinical practice). A prefix denotes the number of months the treatment should be given for; a subscript denotes intermittent dosing (so 3 means three times a week) and no subscript means daily dosing. Most regimens have an initial high-intensity phase, followed by a continuation phase (also called a consolidation phase or eradication phase): the high-intensity phase is given first, then the continuation phase, the two phases divided by a slash. So,
2HREZ/4HR3 means isoniazid, rifampicin, ethambutol, pyrazinamide daily for two months, followed by four months of isoniazid and rifampicin given three times a week. Several studies have shown that the combination of rifampicin, isoniazid, pyrazinamide has increase the risk of drug-induced liver injury. In the US only, streptomycin is not considered a first line drug by ATS/IDSA/CDC because of high rates of resistance. WHO has made no such recommendation.
Second line The second-line drugs (WHO groups 2, 3, and 4) are only used to treat disease that is resistant to first line therapy (i.e., for extensively drug-resistant tuberculosis (XDR-TB) or multidrug-resistant tuberculosis (MDR-TB)). A drug may be classified as second-line instead of first-line for one of three possible reasons: 1) it may be less effective than the first-line drugs (e.g., p-aminosalicylic acid), 2) it may have toxic side-effects (e.g., cycloserine), or 3) it may be effective, but unavailable in many developing countries (e.g., fluoroquinolones):
aminoglycosides (WHO group 2): e.g., amikacin (AMK), kanamycin (KM) polypeptides (WHO group 2): e.g., capreomycin, viomycin, enviomycin fluoroquinolones (WHO group 3): e.g., ciprofloxacin (CIP), levofloxacin, moxifloxacin (MXF) thioamides (WHO group 4): e.g. ethionamide, prothionamide cycloserine (WHO group 4) terizidone (WHO group 5)
Third line Third-line drugs (WHO group 5) include drugs that may be useful, but have doubtful or unproven efficacy:
rifabutin macrolides: e.g., clarithromycin (CLR); linezolid (LZD); thioacetazone (T); thioridazine; arginine; vitamin D; bedaquiline. These drugs are listed here either because they are not very effective (e.g., clarithromycin) or because their efficacy has not been proven (e.g., linezolid, R207910). Rifabutin is effective, but is not included on the WHO list because, for most developing countries, it is impractically expensive.
Standard regimen
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