Authors: Kavitha Saravu, MD, DNB, DTM&H; Madhukar Pai, MD, PhD
Number of pages: 6
Download (2018, pdf, 132kb)
Overview: The success of tuberculosis treatment rests on multidrug antituberculosis therapy at least for six months. During the prolonged course of therapy, patients and providers may confront many adverse drug events (ADE). While minor ADE are common, some are rare and potentially life threatening. Hence it becomes obligatory for the providers to anticipate ADE during therapy, and take necessary measures when ADE occur. The common adverse events are mild elevation of liver enzymes, skin rash, gastrointestinal intolerance, neuropathy and arthralgia and can be managed symptomatically without discontinuation of the offending drugs. Serious adverse events are severe hepatitis, Steven Johnson syndrome, immune thrombocytopenia, agranulocytosis, hemolysis, renal failure, optic neuritis and ototoxicity. These warrant immediate stoppage of drugs and in some cases contraindicate re-challenge. Single most important factor to prevent adverse patient outcomes in terms of severe/chronic disease or fatality is prompt recognition of ADE, discontinuation of the probable drug/s with appropriate evaluation and management. Patients must be educated about symptoms of adverse events and asked to report them promptly. Prevention of monotherapy during the management of ADE is critical to prevent emergence of drug resistant TB.
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Adverse Drug Events With Anti TB Therapy
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Question 1 of 5
1. Question
Which of the following drugs has the highest potential to produce exfoliative dermatitis?
Correct
The correct answer is (c). The propensity of the drugs to cause erythroderma (exfoliative dermatitis) are PZA >SM >EMB >RIF >INH with rates for PZA being 2.4 %. All the drugs have to be stopped and reintroduction of the ATT is to be done with INH followed by RIF, EMB and PZA with careful monitoring. To prevent monotherapy, 2 new drugs which were not used previously should be added while introducing individual drugs.
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The correct answer is (c). The propensity of the drugs to cause erythroderma (exfoliative dermatitis) are PZA >SM >EMB >RIF >INH with rates for PZA being 2.4 %. All the drugs have to be stopped and reintroduction of the ATT is to be done with INH followed by RIF, EMB and PZA with careful monitoring. To prevent monotherapy, 2 new drugs which were not used previously should be added while introducing individual drugs.
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Question 2 of 5
2. Question
Which of the following adverse events is a contraindication to rechallenge of the possibly implicated drug during treatment with ATT?
Correct
The correct answer is (c). Drug induced thrombocytopenia is because of immune mediated mechanisms because of production of autoantibodies or drug dependent antibodies resulting in rapid destruction of platelets. It is a life threatening complication and is an absolute contraindication to rechallenge as even minute quantities of the drug can trigger immune mediated destruction of platelets leading to severe hemorrhage.
Incorrect
The correct answer is (c). Drug induced thrombocytopenia is because of immune mediated mechanisms because of production of autoantibodies or drug dependent antibodies resulting in rapid destruction of platelets. It is a life threatening complication and is an absolute contraindication to rechallenge as even minute quantities of the drug can trigger immune mediated destruction of platelets leading to severe hemorrhage.
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Question 3 of 5
3. Question
Which of the following ATT drugs has no hepatotoxicity potential?
Correct
The correct answer is (d). The propensity to produce hepatotoxicity is with PZA> INH> RIF. Ethambutol, streptomycin and moxifloxacin do not have hepatotoxic potential and they can be administered safely in patients with hepatotoxicity while discontinuing those drugs with hepatotoxic potential and to accompany the individual drugs on rechallenge to prevent monotherapy .
Incorrect
The correct answer is (d). The propensity to produce hepatotoxicity is with PZA> INH> RIF. Ethambutol, streptomycin and moxifloxacin do not have hepatotoxic potential and they can be administered safely in patients with hepatotoxicity while discontinuing those drugs with hepatotoxic potential and to accompany the individual drugs on rechallenge to prevent monotherapy .
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Question 4 of 5
4. Question
Which of the following is a risk factor for ATT induced hepatitis?
Correct
The correct answer is (d). Advancing age, female gender, chronic alcohol consumption, pre existing liver diseases, hepatitis B, C and HIV coinfection, malnutrition are some of the important risk factors for drug induced hepatotoxicity. They have to be carefully sought prior to the initiation of ATT and their presence warrant close monitoring of liver function tests every 2-4 weeks on therapy.
Incorrect
The correct answer is (d). Advancing age, female gender, chronic alcohol consumption, pre existing liver diseases, hepatitis B, C and HIV coinfection, malnutrition are some of the important risk factors for drug induced hepatotoxicity. They have to be carefully sought prior to the initiation of ATT and their presence warrant close monitoring of liver function tests every 2-4 weeks on therapy.
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Question 5 of 5
5. Question
Which of the following is false regarding adverse reactions to TB drugs?
Correct
The correct answer is (a). Jaundice is a sign of hepatitis and warrants stoppage of all TB medications, and investigations for druginduced hepatitis. However, it can also occur rarely due to drug induced hemolysis which is a life threatening complication. Liver function tests and complete blood counts are to be requested to differentiate drug induced hepatitis and hemolytic jaundice. Drug induced hepatitis is diagnosed when serum aminotransferase level >5 times the upper limit of normal [ULN] without symptoms or >3 times the ULN with symptoms.
Incorrect
The correct answer is (a). Jaundice is a sign of hepatitis and warrants stoppage of all TB medications, and investigations for druginduced hepatitis. However, it can also occur rarely due to drug induced hemolysis which is a life threatening complication. Liver function tests and complete blood counts are to be requested to differentiate drug induced hepatitis and hemolytic jaundice. Drug induced hepatitis is diagnosed when serum aminotransferase level >5 times the upper limit of normal [ULN] without symptoms or >3 times the ULN with symptoms.