TREATMENT OF TUBERCULOSIS

1. Treatment of
Tuberculosis
Joslin Pratheeja J - 36
3RD YEAR

2. Objectives
• Classification of Antitubercular drugs
• Properties of Antitubercular drugs
• Objectives of Multidrug therapy
• RNTCP Guidelines for the treatment of
Tuberculosis
• Treatment of different kinds of drug resistant
tuberculosis

3. ANTI TUBERCULAR DRUGS

4. GROUP 1( 1ST LINE ORAL DRUGS)
• Drugs include ISONIAZID(H), RIFAMPIN(R),
PYRAZINAMIDE(Z) and ETHAMBUTOL(E)
• Most potent
• Best tolerated oral drugs
• Routinely used
• Isoniazid, Rifampin, Pyrazinamide have tuberculocidal
property, while Ethambutol has tuberculostatic property.

5. • MOA:
• ISONIAZID - inhibits mycobacterial cell wall synthesis
• RIFAMPIN - bind to bacterial DNA dependent RNA
polymerase and inhibits RNA synthesis
• PYRAZINAMIDE - it kills tubercle bacilli but by an
unknown mechanism
• ETHAMBUTOL - inhibits Arabinosyl transferase enzyme
that are involved in mycobacterial cell wall synthesis

6. GROUP 2 (INJECTABLE DRUGS)
• Includes Aminoglycosides like STREPTOMYCIN(S),
AMIKACIN(Am), KANAMYCIN(Km) and
CAPREOMYCIN
• Potent
• Tuberculocidal property
• Injectables in Nature
• STREPTOMYCIN is used as 1st line drug while
Amikacin, Kanamycin, Capromycin are used as 2nd
line drug in the treatment of TB.
• MOA: inhibits protein synthesis

7. GROUP 3 (FLUOROQUINOLONES)
• Drugs include OFLOXACIN, LEVOFLOXACIN,
CIPROFLOXACIN and MOXIFLOXACIN.
• Well tolerated
• Tuberculocidal property
• Oral drugs
• According to RNTCP guidelines, All patients
with drug resistant TB should receive one
Fluoroquinolones

8. GROUP 4 (2ND LINE ORAL DRUGS)
• Drugs include ETHIONAMIDE,
PROTHIONAMIDE, CYCLOSERINE,
TERIZIDONE, PAS, RIFABUTIN and
RIFAPENTINE.
• Less effective
• Tuberculostatic property
• More toxic than 1st line oral drugs

9. GROUP 5 (UNCLEAR EFFICACY
DRUGS)
• Drugs include BEDAQUILINE,
CLARITHROMYCIN, CLOFAZIMINE,
LINEZOLID, THIOACETONE.
• Drugs with unclear efficacy
• NOT recommended for MDR-TB
• May be used as RESERVE DRUGS ( in XDR-TB)

11. The WHO recommends the use of MDT for all cases of TB
OBJECTIVES OF MDT
1. To make the patient non-infectious as early as
possible and decrease transmission of disease
2. To prevent the development of Drug resistant bacilli
3. To prevent relapse
4. To reduce the total duration of effective therapy

12. RNTCP GUIDELINES FOR THE
TREATMENT OF TUBERCULOSIS
• RNTCP was launched in India in 1997.
Under this programme, Directly Observed Treatment, Short-
course(DOTS) is being implemented. In DOTS, patient who is taking drugs
is directly observed by the health worker or other trained person to ensure
that drugs are actually consumed, thus prevents the emergence of drug-
resistant TB
Fixed Dose Combination(FDC) was introduced. FDC refers to
combination of 2 or more drugs of fixed dose to give one formulation. 2
Types of FDC are introduced in this treatment programme
1. 4 FDC Contains H(75mg), R(150mg), E(275mg), Z(400mg) used in
Intensive phase
2. 3 FDC Contains H(75mg), R(150mg), E(275mg) used in
continuation phase

13. TREATMENT OF DRUG-
SENSITIVE TUBERCULOSIS
• In this case, patient’s bacilli is susceptible to all 1st line
drugs
• All first line antitubercular drugs are used in the
treatment of drug sensitive tb

14. The main objective of intensive phase is to rapidly kill the bacilli and render
the patient noncontagious .
The continuation phase helps to eliminate the remaining bacilli and prevents
relapse

16. TREATMENT FOR MULTI-DRUG
RESISTANT TUBERCULOSIS(MDR-
TB)
• In this case, patients bacilli is resistant to both
RIFAMPIN AND ISONIAZID
• And may/may not be resistant to other 1st line Drugs
• STANDARD RNTCP Regimen for MDR-TB consists
of
• 6 drugs in “intensive phase” (for 6 to 9 months)
• 4 drugs in “continuation phase”(for 18 months)

17. Pyridoxine(100mg/day) should be added to the above regimen

18. TREATMENT OF RIFAMPIN
RESISTANT TUBERCULOSIS
• In this case, patient bacilli is resistant to only
RIFAMPICIN and not Isoniazid
• And may/may not be resistant to other antitubercular
drugs
• According to WHO and RNTCP, RR-TB should be treated
as MDR-TB
• Since patients with RR-TB are sensitive to Isoniazid,
Isoniazid is also added to intensive phase as well in
continuation phase.

19. Pyridoxine(100mg/day) is added to the above regimen

20. TREATMENT OF MONODRUG
RESISTANT TUBERCULOSIS
• In this case, patients bacilli is resistant to anyone 1st line
drug(Except RIFAMPICIN)
• Pyridoxine (100mg/day) should be added to the above regimen

21. TREATMENT OF POLYDRUG
RESISTANT TUBERCULOSIS(PDR-TB)
• In this case, patients bacilli is resistant to more than one
1st line antitubercular drugs( except RIFAMPICIN and
ISONIAZID)

22. Pyridoxine(100mg/day)should be added to the above
regimen)

23. TREATMENT OF EXTENSIVE DRUG
RESISTANT TUBERCULOSIS(XDR-
TB)
• In this case, patients bacilli is resistant to
FLUOROQUINOLONES and 2nd line injectable
antitubercular drugs(eg. Amikacin, Kanamycin and
Capreomycin)
• It is extremely difficult to treat and has high mortality
rate.
• According to RNTCP regimen,
• 7 drugs should be used in “ïntensive phase( for 6 – 12
months)
• 6 drugs should be used in “continuation phase”(for 18
months)

24. Pyridoxine(100mg/day) should be added to the above regimen