Tuberculosis is a chr. Inf. disease caused byM.tuberculosis/M.bovis mainly affecting the lungs causing PTB & EPTB,Different subpopulation of the organism are found Difficult to treat 1.Most antibiotics are effective against rapidly growing organism in contrast to M.tb which is slow growing 2. Mycobacterium Cell can be dormant, thus completely resistant to many antibiotics / killed very slowly by few drugs 3.The lipid rich mycobacterium Cell wall is impermeable to many dru.gs4A substantial proportion are intracellular &chemo therapeutic agents penetrate poorly 5Mycobacterium =>develop resistance to any single drug 6 Caseation &fibrosis block the b.v. supplying necrotic area thus penetration of antitubercular drug difficult.Sputum examination is the gold standard for Diagnosis. First line Drug(Essential AntiTB) have ,High Anti TB effect, Acceptable degree of toxicity&Used routinely.SECOND LINE DRUG (RESERVE ANTI TB DRUG) have, Low anti TB effect, High toxicity or both&Used in special circumstances only. , Characterized by Cough lasting > 2 wks and not respond. to usual antibiotic Production of purulent, sometimes blood- stained sputum Evening rise of temp. Night sweat Weight loss 

1. Dr. Rajendra K. Panda, M.D
Asst.Prof, PHARMACOLOGY
S.C.B. Medical College, Cuttack
Pharmacotherapy
of Tuberculosis(I)

2. INTRODUCTION:
Tuberculosis is a chr. Inf. disease
Caused by M.tuberculosis/M.bovis
Mainly affecting the lungs causing PTB
Also affect other parts causing EPTB
Characterized by
Cough lasting > 2 wks and not respond. to usual antibiotic
Production of purulent, sometimes blood- stained sputum
Evening rise of temp.
Night sweat
Weight loss

3. Extra Pulmonary TB
i. Lymph node TB
ii. Pleural TB
iii. TB of upper airways
iv. Skeletal TB
v. Genitourinary TB
vi. Miliary TB*
vii. Pericardial TB
viii. Gastrointestinal TB (Koch’s Abdomen)
ix. Tuberculous Meningitis
*A "miliary" pattern of spread can occur in which there are a myriad of small millet
seed (1-3 mm) sized granulomas, either in lung or in other organs.

4. Transmission of the disease

5. Mycobacterium tuberculosis
gram +ve bacilli
Nonmotile,nonsporing&noncapsulated
Strict aerobes
Branching filamentous forms ≈ fungal
mycelium =>MYCOBACTERIUM
A.F.B => when stained by Carbol Fuschin by
Z-N Stain they resist decolorisation by 25% H2S04
&Abs.alcohol
Cell wall is lipid rich with mycolic acid which is
essential & unique component

6. Mycobacterial Cell Wall
Arabinoglycan
Peptidoglycan
Mycolates
Lipoarabinomannan(LAM)
Porin
Lipid Bilayer
Acyl lipid

7. Diff. Subpopulation of M. tb
Rapid Growing
Slow growing
Spurters Dormant

9. RISK FACTORS
• HIV infection
• Children exposed to high risk adults
• Close contacts of persons known/suspected
active disease
• Silicosis
• Prolonged corticosteroid therapy
• Other immunosuppressive therapy
• Low body weight (10% or more below the ideal)
• Diabetes mellitus
• Residents and employees of high-risk congregate
settings
• Patients with CRF

10. Difficult to treat:
1.Most antibiotics are effective against rapidly growing
organism in contrast to M.tb slow growing
2. Mycobacterium Cell can be dormant, thus completely
resistant to many antibiotics / killed very slowly by few drugs
3.The lipid rich mycobacterium Cell wall is impermeable to
many drugs.
4. A substantial proportion are intracellular &chemo
therapeutic agents penetrate poorly
5 Mycobacterium =>develop resistance to any single drug
6 Caseation &fibrosis block the b.v. supplying necrotic area
thus penetration of antitubercular drug difficult

11. Diagnostic
Algorithm for
PTB
Cough for 2wks or more
2sputum smear
1OR 2POSITIVE 2NEGATIVE
XRAY chest
ANTIBIOTICS FOR 10-14 DAYS
COUGH PERSIST
REPEAT 2sputum smear NEGATIVE
1OR 2POSITIVE
SUGGESTIVE
0F TB
SMEAR POSITIVE TB
Initiate ATT
NONTB
SMEAR NEGATIVE TB
Initiate ATT

12. X- Ray Findings

13. Aims of Treatment
Prevent death
Cure the pt.
Prevent relapse
Prevent transmission
Prevent development of
Drug resistance

14. Classification of Antitubercular
Drugs (Old Classification )
First line Drug(Essential AntiTB)
High Anti TB effect
Acceptable degree of toxicity
Used routinely
1.. ISONIAZID(H)
2. RIFAMPICIN(R)
3. PYRAZINAMIDE(Z)
4. ETHAMBUTOL(E)
5. STREPTOMYCIN(S)

15. Contd.
SECOND LINE DRUG (RESERVE ANTI TB DRUG)
Low anti TB effect
High toxicity or both
Used in special circumstances only
 PAS
 AMIKACIN NEWER DRUGS
 CAPREOMYCIN -CIPROFLOXACILLIN
 ETHIONAMIDE -OFLOXACILLIN
 KANAMYCIN -CLARITHROMYCIN
 CYCLOSERINE -AZITHROMYCIN
-RIFABUTIN

16. Rationale behind Combination Therapy
To prevent emergence of resistant bacilli
Drugs like H & R act synergistically & Z is more
active during the inflammatory states
Duration of treatment is reduced
To act simultaneously with all subpopulation of
Mycobacterium tuberculosis

17. GROUP I:
First line Anti Tubercular
(ORAL)
1. Isoniazid (H)
2. Rifampin (R)
3. Pyrazinamide (Z)
4. Ethambutol (E)
GROUPII:
Injectable Drugs:
1.Streptomycin (S)
2.Kanamycin (Km)
3.Amikacin (Am)
4.Capreomycin (Cm)
GROUP V:
Unclear Efficacy Drugs
1.BEDAQUILINE
2.DELAMANID
3.Clarithromycin
4.Clofazimine
5.Linezolid
6.Coamoxyclav
7.Imipenum/ Cilastatin
GROUP IV:
Second line Anti Tubercular
(ORAL)
1. Ethionamide (Eto)
2. Prothionamide (Pto)
3. Cycloserine (Cs)
4. Terizidone (Trd)
5.Paraaminosalicylicacid (PAS)
6. Rifabutin
7. Rifapentine
GROUPIII:
Fluoroquinolones
1.Ofloxacin (Ofx)
2.Levofloxacin(Lvx/Lfx)
3.Moxifloxacin (Mfx)
4.Ciprofloxacin (Cfx)
New Classification