Authors: Lancelot M. Pinto, MD, MSc—Author; Madhukar Pai, MD, PhD—co-author and Series Editor
Number of pages: 4
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Overview: Nearly 50% of patients with TB in India are treated in the private sector. GPs therefore share the responsibility of TB control in India, and play a major role in preventing the spread of the disease by curing patients and arresting transmission. Every GP will need to consider TB as a differential diagnosis in persons with cough lasting two weeks or more, or with abnormal findings on chest radiography. In such patients, TB must first be microbiologically confirmed, either using sputum smear microscopy, Xpert MTB/RIF (i.e., GeneXpert), or liquid cultures. Once TB is confirmed, the next step is to begin the correct anti-tuberculosis therapy (ATT) regimen, as recommended by Standards for TB Care in India (STCI) and the International Standards for TB Care (ISTC). All patients who have not been treated previously and do not have other risk factors for drug resistance should receive a WHO-approved first-line treatment regimen for a total of 6 months. The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide and ethambutol. The continuation phase should consist of isoniazid and rifampicin given for 4 months (ethambutol can also be added to the continuation phase in areas with high levels of isoniazid resistance). Treatment can be given daily or as thrice-weekly intermittent dosing. Adherence to the full course of ATT is very important to ensure high cure rates and to prevent the emergence of drug-resistance. If patients have any risk factors for drug-resistance, or do not respond to standard ATT, they must be investigated for MDR-TB using drug-susceptibility tests (DST) like GeneXpert, line probe assays, and liquid cultures. MDR-TB requires long-term and specialized treatment. So, patients should be referred to chest specialists, either in the private sector, or in the public sector where free MDR treatment is available.
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Treatment of Pulmonary Tuberculosis: What Every GP Should Know
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Question 1 of 5
1. Question
Which of the following is the correct drug regimen for a newly diagnosed patient with pulmonary tuberculosis?
Correct
The correct answer is (c). Injectable drugs are not part of the regimen for newly diagnosed pulmonary tuberculosis. The standard regimen for the treatment of TB lasts 6 months, with 4 drugs (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) prescribed in the first two months (intensive phase), and Rifampicin and Isoniazid continued for another 4 months (continuation phase). In India, because of high levels of INH resistance, the Standards for TB Care in India recommends the addition of ethambutol to the continuation phase.
Incorrect
The correct answer is (c). Injectable drugs are not part of the regimen for newly diagnosed pulmonary tuberculosis. The standard regimen for the treatment of TB lasts 6 months, with 4 drugs (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) prescribed in the first two months (intensive phase), and Rifampicin and Isoniazid continued for another 4 months (continuation phase). In India, because of high levels of INH resistance, the Standards for TB Care in India recommends the addition of ethambutol to the continuation phase.
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Question 2 of 5
2. Question
Which of the following tests should be used to monitor the success of treatment for a patient with pulmonary tuberculosis?
Correct
The correct answer is (b). Sputum smear examination is recommended at the end of the intensive phase of treatment and at the end of treatment. Investigations for drug resistant TB need to be performed if the smear continues to be positive at 3 months. Treatment is considered to have failed if the smear at end of treatment is positive. Improvements in chest radiographs, while reassuring in the clinical context, are not specific enough to be used to monitor disease. TB IgG and IgM are serological tests that have been banned and have no role in the management of TB) IGRA (e.g., TB Gold) is a test to diagnose latent TB, and has no role in the diagnosis or monitoring of active disease.
Incorrect
The correct answer is (b). Sputum smear examination is recommended at the end of the intensive phase of treatment and at the end of treatment. Investigations for drug resistant TB need to be performed if the smear continues to be positive at 3 months. Treatment is considered to have failed if the smear at end of treatment is positive. Improvements in chest radiographs, while reassuring in the clinical context, are not specific enough to be used to monitor disease. TB IgG and IgM are serological tests that have been banned and have no role in the management of TB) IGRA (e.g., TB Gold) is a test to diagnose latent TB, and has no role in the diagnosis or monitoring of active disease.
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Question 3 of 5
3. Question
When should one suspect the possibility of drug-resistant TB?
Correct
The correct answer is (d). Relapse, retreatment and having a close contact with drug-resistant TB are important risk factors for drug-resistant TB, and questions pertaining to these risk factors are very important in the initial assessment of patients with TB)
Incorrect
The correct answer is (d). Relapse, retreatment and having a close contact with drug-resistant TB are important risk factors for drug-resistant TB, and questions pertaining to these risk factors are very important in the initial assessment of patients with TB)
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Question 4 of 5
4. Question
Which of the following statements is true about intermittent treatment?
Correct
The correct answer is (c). While intermittent treatment is an accepted modality of treatment, it is recommended only when compliance is ensured through direct supervision, and given for a minimum of three times a week. Twice-weekly regimens are not acceptable. Injectable drugs are not part of a standard intermittent treatment regimen for newly diagnosed pulmonary TB).
Incorrect
The correct answer is (c). While intermittent treatment is an accepted modality of treatment, it is recommended only when compliance is ensured through direct supervision, and given for a minimum of three times a week. Twice-weekly regimens are not acceptable. Injectable drugs are not part of a standard intermittent treatment regimen for newly diagnosed pulmonary TB).
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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 drug-induced hepatitis. It is more common in the elderly and in patients with pre-existing liver disease.
Incorrect
The correct answer is (a). Jaundice is a sign of hepatitis and warrants stoppage of all TB medications, and investigations for drug-induced hepatitis. It is more common in the elderly and in patients with pre-existing liver disease.
