Pharm-TB
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72 terms
Terms | Definitions |
|---|---|
 Pulmonary TB Primary Disease | Usually clinically and radiographically silent, immune system does not eradicate mycobacteria |
| Pulmonary TB Secondary (Reactivation) Disease | Reactivation of latent infection |
| Secondary TB early disease sxs | Nonspecific and insidious onset with fever, night sweats, weight loss, anorexia, weakness, and malaise |
| Secondary TB disease progression sxs | Cough develops, nonproductive at first, then productive of purulent sputum, often blood-streaked |
| galloping consumption | 1/3 of untreated patients die from severe disease within a few weeks to months |
| Organs other than lungs affected in 1/3 of TB cases | Lymph node (40%), Pleura (20%), GU (15%) |
| Purified Protein Derivative (PPD) Skin Test can give false-negative is | overwhelming disease, immunosuppressed |
| Purified Protein Derivative (PPD) Skin Test can give false-positive if | non-TB mycobacteria infection, Bacille Calmette-Guerin (BCG) vaccine |
| QuantiFERON-TB Gold (QTF-G) Blood Test measures | component of cell-mediated immune response to Mycobacterium tuberculosis - Interferon-γ release assay (IGRA) |
| Why does the QTF-G blood test have better compliance? | pt does not have to RTC for readings |
| TB Presumptive diagnosis | AFB on microscopic exam |
| TB Definitive diagnosis | isolation of M. tuberculosis in culture or DNA in nucleic acid amplification test |
| TB treatment length minimum | 6 months, bacteria grow slowly |
| How to prevent resistance of TB? | Multidrug Therapy, Directly Observed Therapy (DOT) |
| Why is Directly Observed Therapy (DOT) recommended over self-administered therapy (SAT)? | Reduces resistance, relapse, and mortality, and improves cure rates |
| 1st Line Treatment of Latent TB | Isoniazid (+ pyridoxine) OR rifampin (or rifabutin) +/- isoniazid |
| 1st Line Treatment of Active TB | 1) Isoniazid (+ pyridoxine) 2) Rifampin OR rifabutin 3) Pyrazinamide 4) Ethambutol OR streptomycin +/- fluoroquinolone |
| How long is Isoniazid treatment in latent TB? | 9 months is optimal |
| How long is Rifampin treatment in latent TB? | 4 months |
| When would rifampin be used instead of isoniazid? | if isoniazid resistance or intolerance, or if ≥ 50 y/o |
| When would rifabutin be used instead of rifampin? | for HIV+ on certain ART (therapy) |
| Treatment of Active TB: Initial Phase Therapy for susceptible isolates | Isoniazid (+Pyridoxine) + rifampin + pyrazinamide + ethambutol |
| How long does Initial Phase Therapy last? | 2 months |
| When can ethambutol be stopped | once TB isolate is known to be fully susceptible |
| Treatment of Active TB: Continuation Phase Therapy for susceptible isolates | Isoniazid (+Pyridoxine) + rifampin |
| How long does Continuation Phase Therapy last? | 4 months |
| If the patient does not receive pyrazinamide during the initial phase of therapy, how long is the continuation phase? | 7 months |
| If using DOT, how many times per week do pts take medications? | 3 times/week |
| If using SAT, how many times per week do pts take medications? | daily therapy must be used |
| Treatment of Active TB: Therapy for Possible Isoniazid Resistance | Isoniazid + (rifampin or rifabutin) + pyrazinamide + (ethambutol or streptomycin) +/- Fluoroquinolone |
| Why is pyridoxine always taken with isoniazid? | to prevent side effects of isoniazid |
| Why would a fluoroquinolone be added to Therapy for Possible Isoniazid Resistance? | May strengthen regimen in extensive disease |
| Treatment of Active TB: Isoniazid Resistance Documented | *stop isoniazid; rifampin (or rifabutin), pyrazinamide, and ethambutol (or streptomycin) continued for 6 months |
| Treatment of Active TB: Therapy for Multidrug-Resistant TB | Tx continued for 18-24 months after sputum culture conversion, drugs given QD under DOT; should include 1 injectable + 3 more drugs |
| Treatment of Active TB: Therapy for Extended Drug-Resistant TB | Surgical resection of the infected lung may be considered for patients with MDR- and XDR-TB |
| What does XDR-TB mean? | Isolate that is resistant isoniazid, rifampin, at least one fluoroquinolone, and at least one injectable drug |
| What does MDR-TB mean? | Isolate that is resistant to both isoniazid and rifampin |
| Isoniazid (INH) mechanism of action | Inhibits mycolic acid synthesis (cell wall) - Bactericidal |
| If a person is a genetically determined "fast" acetylator, how would that effect INH therapy? | no effect |
| If a person is a genetically determined "slow" acetylator, how would that effect INH therapy? | drug can stay in the body longer & cause more side effects (typically no therapeutic consequence with appropriate doses) |
| Isoniazid (INH) adverse effects | Peripheral Neuritis, Hepatitis and Hepatotoxicity, DDIs |
| Most common adverse effect of Isoniazid (INH) | Peripheral Neuritis |
| Peripheral Neuritis manifests as | paresthesias of the hands and feet (worse in "slow"acetylators) |
| Peripheral Neuritis is due to what deficiency? | a relative pyridoxine (vitamin B6) deficiency |
| Isoniazid (INH) BBW | Hepatitis and Hepatotoxicity |
| Which DDI is most common for Isoniazid? | Inhibits metabolism of phenytoin |
| Rifampin (RMP) Mechanism of Action | Inhibits bacterial RNA synthesis; Effective against mycobacteria, gram+ and gram- cocci, chlamydia, and some enterics - Bactericidal |
| Rifampin (RMP) is also used for | leprosy, atypical mycobacterial infections, and asymptomatic N. meningitidis carriers (not infection) |
| Rifampin (RMP) Adverse Effects | Orange-Red Color to Secretions, Urine, Feces; Hepatotoxicity, DDIs |
| What are the most common DDI's for rifampin? | Induces metabolism of methadone, some anticonvulsants, cyclosporine, some antifungals, warfarin, contraceptive steroids |
| Why does rifabutin have less DDI's than rifampin? | Rifabutin is less potent inducer of P450 enzymes |
| Rifabutin Mechanism of Action | Derivative of rifampin, similar action |
| Rifabutin Adverse Effects | Similar to rifampin, but less DDIs; Also uveitis, skin hyperpigmentation, and neutropenia |
| Pyrazinamide (PZA) Mechanism of Action | Unknown, may relate to lowered pH - Bactericidal |
| How does Pyrazinamide (PZA) affect TB therapy time? | Reduces therapy for active TB from 9 months to 6 |
| Pyrazinamide (PZA) Adverse Effects | Hyperuricemia, Hepatotoxicity, Photosensitivity |
| Ethambutol (EMB) Mechanism of Action | Unknown, may inhibit RNA synthesis - Bacteriostatic |
| When would Ethambutol (EMB) be stopped during TB treatment? | Stopped if isolate is sensitive to isoniazid and rifampin |
| Ethambutol (EMB) Adverse Effects | Optic Neuritis, Hepatotoxicity, Hyperuricemia |
| Ethambutol (EMB) induced Optic Neuritis results in | diminished visual acuity and reduction in red-green discrimination; Reversed with discontinuation |
| Streptomycin (SM) Mechanism of Action | Aminoglycoside antibiotic - Bactericidal |
| When is Streptomycin (SM) used in TB treatment? | Used when an injectable drug is needed |
| What agents can be used if there is resistance to SM? | Kanamycin or amikacin |
| Streptomycin (SM) Adverse Effects (BBWs) | Ototoxic, Nephrotoxic, Neuromuscular (Including Respiratory) Paralysis |
| Second-line drugs, for MDR-TB | 1) Kanamycin, Amikacin, or Capreomycin (Aminoglycosides) 2) Pyrazinamide 3) Ethambutol 4) Fluoroquinolone 5) Rifabutin 6) Cycloserine |
| Cycloserine Mechanism of Action | Inhibits cell wall synthesis |
| Cycloserine adverse effects | CNS disturbances, seizure exacerbation, and peripheral neuropathy |
| Drugs for Leprosy | Dapsone + rifampin + clofazimine: 12 month therapy |
| When is PPD ≥ 5 mm induration positive for TB? | if recent contact with active TB, HIV+, immunosuppressed, healed TB on CXR, or if on ≥ 15 mg prednisone/day |
| When is PPD ≥ 10mm induration positive for TB? | if from country with high prevalence, IV drug user, low socioeconomic status, chronic illness, nursing home resident, prisoner, or healthcare worker |
| When is PPD ≥15 mm induration positive for TB? | all others (low risk) |
| Can PPD testing discriminate between latent and active disease? | NO |
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