The document discusses tuberculosis (TB) treatment in special situations, including during COVID-19, pregnancy, in the elderly, and in patients with renal or hepatic diseases. It emphasizes the importance of adjusting treatment based on individual circumstances, such as medication interactions and organ function considerations. Key points include safe drug usage during pregnancy, the need for careful monitoring in patients with liver and kidney disease, and specific protocols for TB treatment in the context of HIV/AIDS.

1. Tuberculosis in Special
Situations
Dr. K.Deepak Kanna MD
Assistant Professor , Dept of Respiratory
Medicine
Govt Medical College Hospital , Virudhunagar

2. TREATMENT OF TB IN SPECIAL SITUATIONS
• TB in COVID
• TB in PREGNANCY / LACTATION
• TB in ELDERLY
• TB in Pts with HEPATIC DISEASES
• TB in Pts with RENAL DISEASES
• TB in HIV/AIDS
• TB in Children

3. TB in COVID Patients
• No interaction between ATT drugs and drugs
used during Covid .
• The dose of Steroids had to be adjusted while
treating Covid and tapered.
• ATT can be started along with Covid Positive
status and Diagnosed TB at same time.
• Vaccination to be avoided to patients on ATT
before determining the cause of acquiring the
infection ( Immuno suppression, DM, Drugs,etc)

4. TB IN PREGNANT AND LACTATING WOMEN
• Before starting ATT, women of childbearing age
group should be asked about current
pregnancy status / planned pregnancy and
counselled appropriately.
• Safe ATT drugs in Pregnancy & Lacatation –
CAT- I - H R Z E
• ATT contra indicated –Cat II - Inj Streptomycin
( ototoxic to foetus )

5. • No modification in ATT and can continue full course .
• Breast feeding has to be continued.
• After ruling out active TB , the baby should be given
6 months of Isoniazid preventive therapy for 6
months followed by BCG vaccination. Breast feeding
should not be discouraged.
• Mother must be advised cough hygiene measures
such as covering the nose and mouth while coughing
, sneezing or any act which produces sputum
production droplets.
• Mothers receiving INH and their breastfed infants
should be supplemented with vitamin B6
(pyridoxine)(5mg/day)

6. MDR TB in Pregnancy
• Teratogenicity is demonstrated with drugs used to
treat MDR – TB
• Women diagnosed MDR TB should be counselled
intensively to use birth control measures and the
risk of taking MDR drugs for the mother and the
foetus
• Duration of pregnancy is less than 20 weeks –
advise – MTP (Medical Termination)
• If Duration more than 20 weeks – Modified MDR
ATT drugs should be given to her.

7. TB in Patients on OCP
• Rifampicin and Rifapentine interacts with
oral and hormonal contraceptive
medications – CYP450 and reduces the
efficacy of OCP and hence should be
advised to use alternative anti
contraception methods ( Condoms /
diaphragm) , IUDs, or depot –
metroxyprogesterone.

8. TB in Liver disorders
• Pts with Hepatitis virus carriage, past history of acute
hepatitis, current excessive alcohol consumption can
receive -H R Z E but hepatotoxicity to be anticipated.
• Liver function test has to be taken at beginning of ATT and
periodically during the course.
• If the Serum ALT –is raised 3 times the normal then
modification of the drugs is needed.
The normal range of values for ALT (SGPT) is about 7 to 56
units per liters of serum – eg. 50 U– then more than 150U is
at upper limit
• Elderly , alcoholics and pre existing liver diseases patients
are prone to develop Hepatotoxicity.

9. • Hepatatoxic drugs in ATT first line – H R Z
second line ATT- PAS granules, Ethionamide
• Hepato safe drugs – E , Streptomycin , Fluoro
quinolones ( Levofloxacin , Ofloxacin ) .
• In patients with hepatotoxicity – SEO
regimen – streptomycin , ethambutol ,
Ofloxacin .
• ATT challenging test to find the causative
drug in H R Z. ( in special situations only)

10. TB in Renal diseases.
• Patients suffering from Chronic kidney disease are at increased risk
of developing TB.
• Post renal transplant and other renal diseases pts are to be
counselled to avoid all risk factors in acquiring TB infections.
• Renal safe ATT drugs – HRZ
• Renal toxicity drug- most - Ethambutol
- in moderate renal impairment – FQs, PAS, Cycloserine
• Creatinine Clearance test have to be calculated and determine.
• Dialysis and ATT drugs – can be gven 4-6 hrs after E and Z.
• Post renal transplant – Rifampicin interacts with
immunosuppressive drugs, hence corticosteriods dose should be
doubled in pts receiving Rifampicin.

11. TB and HIV
• TB – Diabetes – HIV
• Newly diagnosed TB in HIV –
• First start ATT – HRZE and do not give ART for the
first 15 days .
• Must Start ART after 15 days only, after repeating
Liver Function tests and Renal Functions tests and
found within limits.
• No interactions with ATT and ART drugs but all
drugs can impair the vital organs.

12. TB and HIV
• Previously TLE regimen was used for patients
with HIV and TB co existing
• Recent Guidelines – changed from TLE
regimen (FDC) to T L D regimen
• T – Tenofovir 300mg ; L-Lamivudine 300mg;
E- Efavirenz 600mg
• D- (DRV) Darunavir
Darunavir is given 50mg BD till Rifamycin is given
in ATT and changed to 50mg OD ( as Rif
decreases the conc. of Darunavir )

13. TB in Children
Achieving successful treatment of TB in children depends on a
number of different factors including-
• The child must be promptly diagnosed
• TB treatment must be started promptly
• The correct TB drugs must be provided
• The dosage of the TB drugs must be adjusted according to the
child’s weight
• Support must be provided to ensure that the TB drugs are
taken correctly
• There must be a continuous supply of quality assured TB
drugs.

15. TB in Children
• There are no drugs that are absolutely
contraindicated in children
• Children generally tolerate well for the second-line
anti-TB drugs.
• Weight based Fixed dose regimen to started for
children

16. TB and Seizures
• Rifampicin and Phenytoin
• CYP450
• Rifampicin dose has to be increased in Pts on
Phenytoin
• MDR TB - – Cyclocerine , Ethionamide, FQs
are associated with seizures and psychosis.

17. THANK YOU