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Monitoring Patients on Anti-TB Medications. Reynard J. McDonald, MD Medical Director, Lattimore Practice Northeast National Tuberculosis Center at NJMS. Adverse Side Effect.

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monitoring patients on anti tb medications

Monitoring Patients on Anti-TB Medications

Reynard J. McDonald, MD

Medical Director, Lattimore Practice

Northeast National Tuberculosis Center at NJMS

adverse side effect
Adverse Side Effect
  • Any unexplained, unintended, undesired, or excessive response to a medication, used at recommended doses that may require:
    • Discontinuation of the medication (therapeutic or diagnostic)
    • Modifying the dose (except for minor dosage adjustments)
    • Prolonging treatment
adverse side effects cont d
Adverse Side Effects Cont’d
  • Adverse drug reactions may lead to complications:
    • Prevents optimal drug use in some patients
    • Necessitates supportive care
    • Significantly complicates treatment
    • Decreases patient’s quality of life
    • Results in temporary or permanent harm, disability, or death
scope of problem
Scope of Problem
  • The fourth leading cause of death in the US is adverse drug reactions (ADRs)
  • Only heart disease, cancer, and stroke kill more Americans than ADRs
  • The number of deaths from ADRs is three times the number of deaths from people killed by automobile accidents
risk factors for developing an adr
Risk Factors for Developing an ADR
  • Multiple drug therapy
    • Over the counter medications
    • Alcohol
    • Drugs of abuse
    • Number of drugs
  • Age
    • Very young
    • Very old
  • Pregnancy
    • Risk to fetal development (first trimester, phenytoin)
  • Co-morbidity/chronic diseases – can alter a drug’s absorption, distribution, metabolism or elimination
  • Hereditary factors – slow acetylators
monitoring for adverse reactions
Monitoring for Adverse Reactions
  • Health care workers should be educated about:
    • Name(s) of medication
    • Common side effects
    • More serious reactions
    • What to do if symptoms occur
    • What to do if patients have other behaviors that may interfere with their treatment
    • What to do if a dose is missed
    • How to report an ADR
monitoring for adverse reactions7
Monitoring for Adverse Reactions
  • During treatment, patients should be questioned and evaluated for:
    • Signs and symptoms of possible side effects
  • Use open-ended questions to obtain more information
  • While in the field, health care workers should:
    • Make observations about the patient and the surrounding environment
    • Take appropriate action to address and correct the adverse reaction
how do i report an adr
How Do I Report an ADR?
  • Depends on each individual TB program
    • e.g., telephone, email, fax, or mail
  • Follow the TB Program’s standard procedure for reporting ADRs
  • Ensure complete documentation of all pertinent information
tb medications that can cause an adr
TB Medications That Can Cause an ADR
  • First-Line Anti-TB Medications
    • Isoniazid (INH)
    • Rifampin (RIF)
    • Rifabutin (RFB)
    • Rifapentine (RPT)
    • Ethambutol (EMB)
    • Pyrazinamide (PZA)
  • Second-Line Anti-TB Medications
isoniazid inh
Isoniazid (INH)
  • Adverse effects:
    • Hepatic enzyme elevation
    • Hepatitis
    • Peripheral neuropathy
    • CNS effects
    • SLE-like symptoms
    • Hypersensitivity reaction
    • Monoamine (Histamine/tyramine poisoning)
    • Diarrhea
inh drug interactions monitoring
INH Drug Interactions & Monitoring
  • Drug Interaction
    • Phenytoin
  • Monitoring
    • Routine monitoring is not necessary
    • For patients with pre-existing liver disease or who develop abnormal liver function test should be measured monthly and when symptoms occur
  • Prevention
    • Vitamin B6 may prevent peripheral neuropathy and CNS effects
rifampin rif
Rifampin (RIF)
  • Adverse effects:
    • Cutaneous reactions
    • Gastrointestinal reactions
    • Flu-like syndrome
    • Hepatotoxicity
    • Severe immunologic reactions
    • Orange discoloration of bodily fluids
      • Patients should be informed in advance of urine and contact lens discoloration
rif drug interactions
RIF Drug Interactions
  • Drug Interactions
    • Antiinfectives
    • Hormone therapy
    • Narcotics
    • Anticoagulants
    • Immunosuppressive agents
    • Anticonvulsants
    • Cardiovascular agents
    • Bronchodilators
    • Sulfonylurea hypoglycemics
    • Hypolipidemics
    • Psychotropic drugs
rif monitoring
RIF Monitoring
  • Monitoring
    • No routine monitoring required
    • When given with drugs that interact, may necessitate regular measurements of the serum concentrations of the drugs in question
rifabutin rfb
Rifabutin (RFB)
  • Adverse effects:
    • Hematologic toxicity
    • Uveitis
    • GI symptoms
    • Polyarthralgia
    • Hepatitis
    • Rash
    • Orange discoloration of bodily fluids
  • Drug interactions and monitoring – see RIF
rifapentine rpt
Rifapentine (RPT)
  • Adverse effects:
    • Similar to those associated with RIF
    • May increase metabolism of co-administered drugs that are metabolized by hepatic enzymes
  • Drug Interactions:
    • Are likely to be similar to those of RIF
  • Monitoring:
    • Similar to that for RIF
ethambutol emb
Ethambutol (EMB)
  • Adverse effect:
    • Optic neuritis (impaired perception of the red and green colors)
    • Cutaneous reactions
  • Monitoring
    • Baseline and monthly tests of visual acuity and color vision
    • Educate patient about self monitoring their vision and reporting any visual changes to their physician immediately
pyrazinamide pza
Pyrazinamide (PZA)
  • Adverse effects:
    • Hepatotoxicity
    • GI symptoms
    • Non-gouty polyarthralgia
    • Hyperuricemia
    • Acute gouty arthritis
    • Rash
  • Monitoring
    • Serum uric acid measurements are not routinely recommended
    • Liver function tests should be performed when the drug is used in patients with underlying liver disease
second line anti tb medications
Second-Line Anti-TB Medications
  • Cycloserine
  • Ethionamide
  • Levofloxacin
  • Moxifloxacin
  • Gatifloxacin
  • p-Aminosalicylic acid (PAS)
  • Streptomycin
  • Amikacin/Kanamycin
  • Capreomycin
second line anti tb medications20
Second-Line Anti-TB Medications
  • Cycloserine
    • Psychosis, seizures
  • Ethionamide and PAS
    • GI upset
  • Fluoroquinolones
    • Tendon rupture
  • Aminoglycosides
    • Deafness
    • Renal failure
patient education
Patient Education
  • Health care workers must clearly explain to patients the following:
    • When the medication should be taken
    • How much
    • How often
  • All patients should be educated about:
    • TB
    • Medication dosages
    • Possible side effects
    • Importance of taking the medication
additional challenges
Additional Challenges
  • Close supervision is necessary for patients who abuse alcohol and other drugs to:
    • Ensure adherence
    • Monitor for medication side effects and adverse reactions
  • Directly observed therapy (DOT) and case management can produce the best results
questions to ask
Questions To Ask
  • How do you feel?
  • Do you have any of the following:
      • Abdominal pain
      • Fatigue
      • Unusual breathing
      • Rash
      • Joint pains/swellings
      • Other unusual symptoms
questions cont d
Questions Cont’d
  • Are you taking any medications other than anti-TB medications?
    • Prescription medications, herbal remedies or vitamins
  • How is your appetite?
  • How do you feel after you take the medications?
  • Have you had any weight gain or loss?
  • What color is your urine (should be orange for patients on rifampin)?
  • Do you have any fever?
patient observation
Patient Observation
  • Does the patient have signs and symptoms of hepatitis including any of the following:
      • Yellow eyes
      • Yellow skin
      • Nausea or vomiting
  • Does the patient have any rash?
  • Is the patient gaining weight?
  • Are you having any problems taking the anti-TB medications?
importance of monitoring
Importance of Monitoring
  • Close monitoring of patients throughout treatment can:
    • Prevent serious complications
    • Promote continuity of care
    • Improve patient-health care provider relationship
    • Encourage adherence
    • Ensure successful completion of treatment