Author: Marzieh Ghiasi

The correct answer is (e).

The correct answer is (c). BMI is calculated as weight in kg/(height in metre). The BMI in this patient would be 45/(1.7)2= 15. 57 kg/m2. This is less than 16.0 kg/m2 and indicates severe undernutrition.

The correct answer is (d). The bioavailability and peak serum concentrations of both isoniazid and rifampicin is affected by food.

The correct answer is (c): The commercial protein supplement may contain 40 gm protein in a 200-gm pack, but is costly and inappropriate, as are tonics with amino acids. Mutton and chicken are more expensive than eggs and the labourer is more likely to afford additional pulses or eggs, than eat chicken or mutton on a daily basis. The protein content per 100 gm, does not differ between eggs and chicken.

The correct answer is (b). Isoniazid interferes competitively with pyridoxine metabolism by inhibiting the formation of the active form of the vitamin, and hence often results in peripher¬al neuropathy. This is especially marked in malnutrition, pregnancy, lactation, HIV infection, diabetes and hypertension. This effect can be prevented by giving pyridoxine 10 mg per day.

The correct answer is (a). In a patient with very low BMI and who has probably been eating little for many days, vigorous feeding may result in refeeding syndrome which can be danger¬ous. The feeding should start at 50% of the dietary requirement or even lower in the first few days, along with the other measures mentioned.

The correct answer is (F). Rifampicin often turns body fluids a red-orange color. Alerting patients ahead of time to this benign side effect may help minimize unnecessary concern or interruptions in therapy.

Pyridoxine should be considered for all patients starting TB therapy including isoniazid, but Mohan is at particularly high risk for isoniazid-related peripheral neuropathy due to his diabetes, which can also cause peripheral neuropathy. People living with HIV, malnourished patients, and patients on other medications that can cause peripheral neuropathy (e.g., multidrug resistant TB patients on ethionamide, cycloserine, or linezolid) are also at higher risk for isoniazid-related peripheral neuropathy.

Rifampicin can decrease blood levels of sulfonylureas used to treat diabetes, including glyburide, which can result in worsened blood sugar control in some patients.1,2 As such, patients on sulfonylurea medications should have their diabetes monitored closely, as they may require modifications of their medications while on TB therapy.

There is no specific requirement that patients should take their TB medications only at bedtime. In general, for patients on standard therapy for drug-susceptible TB, it is important that patients take their medications at the same time every day (whether in the morning or at night). TB medications are best absorbed if taken on an empty stomach; however, for patients with significant gastrointestinal side effects, taking medications with food may be considered to reduce these side effects.

The correct answer is (F). Ongoing weight loss after weeks of TB therapy should raise concern for potential drug-resistance, poor medication adherence, and poor quality of the patient’s diet. Per the Standards for TB Care in India, drug susceptibility testing (DST) should be offered to all diagnosed TB patients prior to starting therapy. however, in cases where DST was not done at the initiation of therapy, failure to respond to therapy as evidenced by ongoing weight loss should prompt GPs to send a DST.

Ongoing weight loss may also suggest that a patient is not taking his or her medications, so screening for non-adherence using simple questions (such as the Morisky questions) is important.
Low caloric intake and poor protein intake may blunt replenishment of the patient’s nutritional stores, especially in patients with food insecurity, vegetarian patients with poor protein intake, and patients with a high catabolic state from other comorbidities (e.g., HIV cachexia).

Streptomycin alone should not be added empirically to the patient’s medication regimen. If there is high concern for drug-resistant TB, DST should be performed, and empiric multidrug- resistant TB therapy (which would involve addition of multiple medications) can be considered in some cases pending the DST result.

While a prednisone taper might briefly increase the patient’s weight and temporarily improve symptoms, it would not improve the patient’s long-term response to TB therapy.

The correct answer is (H). Unfortunately, evidence-based data about the best approaches for ensuring adherence to TB medications are lacking. However, some common-sense strategies for improving medication adherence include improving the patient’s treatment literacy (by educating about the consequences of non-adherence), setting daily reminders to facilitate pill-taking, involving close family members in the patient’s TB care, and implementing a “talk back” strategy at each visit, in which the patient repeats back your recommendations to confirm his or her understanding.

Patients should not stop TB medications for acid reflux or mild nausea, though they should get in touch with their GP. GPs can then check LFTs to rule out hepatotoxicity and recommend therapies to reduce these GI side effects, such as antacids.

Maintaining good glycemic control is important during TB therapy, and patients should not be advised to stop their diabetes medications while on TB therapy.

The correct answer is (E). Depression and alcohol use disorder are two common barriers to TB medication adherence. Simple questionnaires—such as the Patient Health Questionnaire- 2 (for depression) and the AUDIT-C (for alcohol use disorder)—can be easily implemented during brief patient visits to screen for these problems. Ideally, patients should be referred to mental health specialists to help with these problems; however, finding a qualified specialist can be difficult in many areas of India. Encouraging compassionate, non-judgmental involvement from a patient’s family members can sometimes provide the social support needed to get through TB therapy.
The patient should not be advised to stop TB therapy, because premature termination of therapy will increase the risk for relapse of TB.

The correct answer is (E). Patients with alcohol use disorder should be reminded about the increased risk of hepatotoxicity from TB medications. Identifying triggers that lead the patient to use alcohol heavily may help patients to reflect upon how they can avoid these triggers and cut down on drinking. For heavy drinkers, eating before drinking may improve nutritional status and blunt the effects of alcohol. It is important to have a non-judgmental approach to patients with substance use disorders. Patients are more likely to have ongoing engagement with healthcare providers who are open and compassionate. Recent studies suggest that supportive engagement of patients with alcohol use disorder can improve their TB treatment outcomes.

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.

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.

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 .

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.

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.