Preventive therapy problems in clinical practice
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PREVENTIVE THERAPY PROBLEMS IN CLINICAL PRACTICE. Uz. Dr. Asiye İNAN SÜER Altındağ , Ankara TB Control Dispensary No. 3 05.04.2013. I have no conflicts of interest to declare. Preventive therapy (PT). *An essential component of national tuberculosis (TB) control programme

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Preventive therapy problems in clinical practice

PREVENTIVE THERAPYPROBLEMS IN CLINICAL PRACTICE

Uz. Dr. Asiye İNAN SÜER

Altındağ, Ankara TB Control Dispensary No.3

05.04.2013


Preventive therapy problems in clinical practice

I have no conflicts of interest to declare.


Preventive therapy pt

Preventive therapy (PT)

*An essential component of national tuberculosis (TB) control programme

*One of the most important duty of tuberculosis control dispensary (TCD):

Preventive therapy at persons with increased risk of TB


Decision to pt

Decision to PT

  • Hospital or TCD

  • Exclusion of active TB disease’

  • Not examined for active TB : propability of isoniazid (H) resistance


Application at tcd

To fill “Preventive Chemotherapy Form”

Chest X-ray

TST

Symptoms and medical history

Hepatic enzyme measurement (>35 years or having risk factors)

Application at TCD


Application at tcd training

Application at TCD-Training

İnformation about preventive therapy

  • Treatment duration

  • Close follow up

  • Regular use of drug

  • Side effects

  • Discontinue treatment at symptom onset, then contact TCD


Nformation forms

İnformation forms


Application at tcd medication

Application at TCD-Medication

  • Planning treatment regimen and dosage

  • Monitoring plan in medical record

  • Free of charge

  • Periodically (usually monthly) given drug (at first meeting 15 days, then 30 days)

  • Pyridoxine (B6 vit)10 mg/day (at risk of peripheral neuropathy)

  • Give appointment and TCD’s telephone number


Pt regimens in turkey

PT regimens in Turkey


Conditions that is necessary alternative regimens

Conditions that is necessary alternative regimens

-Serious side effect with H/or history

-Not suitable 6-9 months treatment

-Contacts of H resistance TB case

-Contacts of MDR TB case


Alternative regimens

Alternative regimens

4 months Rifampin (4R)

(better completion, less toxicity than 9H)

3/4 months Isoniazid+Rifampin (3/4HR)

(equivalent effectiveness, completion of therapy and toxicity has been the same as with H)

3 months İsoniazid+ Rifapentin (3H+RPT)

(>12 years, alternative for 9 H)


Efficacy of 3 months of rifampin for the prevention of tb patients with silicosis

Efficacy of 3 months of Rifampin for the Prevention of TBPatients with Silicosis

Hong Kong Chest Service. Am Rev Respir Dis 1992;145:36-41


Treatment of mdr tb contacts

Treatment of MDR-TB contacts

*Q/QE may be safer, better tolerated .

*Recommendations are based on expert opinion.

Lobue P, Menzies D. Respirology 2010,15:603-622


Follow up treatment

Follow up treatment

  • Periodic control (monthly)

  • Ask: Symptoms- side effects and compliance

  • Train and support

  • Chest X-ray control (three months)

  • Compliance problems: DOT

  • Other hepatotoxic medications


Decision of treatment completion

Decision of treatment completion

According to pause period:

6 months PT--- 9 months

9 months PT--- 12 months

4 months R-PT---6 months

completion is acceptable

*Am J Respir Crit Care Med 2000;161:S221-S247


Problems of application

Problems of application

A-In the beginning of PT

B-At follow up period


Pt in turkey 2013 questionnaire

PT in Turkey-2013(Questionnaire )

  • Aim: PT application and problems faced with/recognized during PT

  • Method: Send to 81 province TB coordinators also all TCDs in İstanbul and Ankara by mail

  • Answer : 69 Questionnaire forms collected

    (41 TB coordinators, İst-23 TCDs, Ank-5 TCDs)


Preventive therapy problems in clinical practice

A

Provinces those answered the Questionnaire (yellow)


A problems faced with in the beginning of pt

A-Problems faced with in the beginning of PT

1-Over indication

2-Wrong medication

3-PT neglicance

4-Age related problems

5-PT without TCD follow up

6-Convincement of person/family


Over indication

Over indication

1-Active TB case

2-History of TB

3-Acut liver disease PT contrindicated


Wrong medication

Wrong medication

PT for H resistance/MDR TB case contacts

Questionnaire :Treatment of MDR LTBI

No------45 , No answer---1 Yes-----23

3 drug?

12 H,

5 H/R/HR

3 different regimen (ZQ/PAS-Q/ PROT-Q/PROT-Z)


Pt negligence

PT negligence

-Physicians knowledge about PT

-Physicians belief about PT

-Lack of HCWs at TCDs

- Lack of experience


Physician s opinions about preventive therapy

Physician’s opinions about Preventive Therapy*

  • A questionnaire was applied to 130 physicians from different specifications

Soysal F. Solunum 3;27-30, 2001


Questionnaire preventive therapy indications

Questionnaire –Preventive therapy indications


Age related problems

Age related problems

  • National TB diagnosis and treatment guideline: Preventive therapy for contacts of TB <35 age

  • The decision to treat LTBI at over 35 years should be made after careful consideration of risks and benefits.

  • Preventive therapy at immunesupressed patients: most of over 35 years, no common side effects


Questionnaire age

Questionnaire –Age


Age related risk of hepatotoxicity

Age-related risk of hepatotoxicity

  • A systematic review, 18.610 participants, 7 relevant studies

  • The median rate of hepatotoxicity;

    aged<35 %0,2

    aged ≥35 %1,7

    “The use of H for the treatment of LTBI is safe in older patients with clinical or biochemical monitoring.”

    Kunst H. Int J Tuberc Lung Dis 2010


Preventive therapy without tcd follow up

Preventive therapy without TCD follow up

-Decision of preventive therapy at hospital

-Not registered TCD

-H at drugstore

-

(Adherence to treatment? Clinical monitoring? Treatment completion?


Convincement of person family

Convincement of person/family

Parent/family training

Communication


Questionnaire

Questionnaire

Problems


B follow up problems

B- Follow up- problems

1- Side effects

2- Compliance to PT

3- Default


Side effects

Side effects

- Peripheral neuropathy

-Hypersensitivity (within days to weeks)

-Hepatic adaptation: asymptomatic, transient elevations of transaminase, %10-20

-Hepatotoxicity (within weeks to months)

nausea, vomiting, abdominal pain, jaundice

or unexplained fatigue


Hepatotoxicity

Hepatotoxicity

Treatment should be interrupted:

  • Transaminase elevation more than three times the upper limit of normal (ULN) in the presence of hepatitis symptoms and/or jaundice

  • Five times the ULN in the absence of symptoms

  • Bilirubin > 1.5 mg/dl


Isoniazid hepatotoxicity

Isoniazid Hepatotoxicity

  • H hepatotoxicity is age related

    3377 patients, 19 hepatotoxicity (5.6 per 1000)

    25-34 years 4.40

    35-49 years 8.54

    ≥50 years 20.83

  • H hepatotoxicity frequently occurs within the first 3 months

    After 1 month 2.75 per 1000

    After 3 month 7.20

    After 6 month 4.10

    Fountain FF. Chest 2005;128:116-23


Conditions that high risk of side effects

Conditions that high risk of side effects

  • Chronic ethanol consumption

  • Pregnant/ 3 months post-partum

  • Viral hepatitis/ pre-existing liver disease

  • Other hepatotoxic medications

  • ALT/AST or bilirubin abnormal

  • Over 35 years

    Baseline and follow-up serum ALT and bilirubin are recommended for patients with risk factors.

    ATS . Am J Respir Crit Care Med 2006;174:935-52


Suboptimal compliance

Suboptimal compliance

1-Duration of therapy (6-9 months)

2-Logistical issues

3-Adequate communication between health department staff and the patient

4-Negative attidutes towards PT

5- Change of the first indication

6-Difficulties in drug intake


The percentage of treatment completers

The percentage of treatment completers


Pt default

PT Default *

E.Kibaroğlu, 4nolu VSD/Ankara, 2012 Toraks kongre sunumu


Questionnaire1

Questionnaire

Problems


Questionnaire the most common problems

Questionnaire –The most common problems


Adherence to treatment in contacts real conditions alberta 1990 91

Adherence to treatment in contactsReal conditions: Alberta 1990-91

2007 Toraks kongresi, D.Emarson’ın sunumundan


Thanks

Thanks


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