Anti TB Drugs

Evelyn B. Yumiaco M.D.

Department of Pharmacology
School of Medicine
Angeles University Foundation
Country Picture
Population 2007 = 88 Million
Global rank 9
th
among HBCs
Regional rank 3
rd
among WPR countries
TB Incidence (New SS+) = 131/100,000
Case Detection Rate 2006 = 74%
Cure Rate (New SS+) 2005 = 82%
Success Rate (New SS+) 2005 = 90%
MORBIDITY 2009
1. ARI
2. ALTI/PNEUMONIA
3. BRONCHITIS/BRONCHIOLITIS
4.HYPERTENSION
5. ACUTE WATERY DIARRHEA
6.INFLUENZA
7. UTI
8. TB (RESPIRATORY)
9. INJURIES
10. ACUTE FEBRILE ILLNESS
DEPARTMENT OF HEALTH
MORTALITY 2009
1. DISEASES OF THE HEART
2. DISEASES OF THE VASCULAR SYSTEM
3. MALIGNANT NEOPLASM
4. PNEUMONIA
5. ACCIDENTS
6. TB (ALL FORMS)
7. CHRONICLOWER RESPIRATORY DISEASES
8. DIABETES
9. NEPHRITIS/NEPHROTIC SYNDROME
10. PERINATAL CONDITIONS
DEPARTMENT OF HEALTH
National TB Program
Manual of Procedure (MOP)
HON. FRANCISCO T. DUQUE III, MD, MSc.
Secretary of Health
Department of Health
December 2005


VISION, MISSION, AND GOAL
OF THE NTP
Vision: A country where TB is no longer
a public health problem
Mission: Ensure that TB DOTS services
are available, accessible, and affordable
to the communities in collaboration with
the LGUs and other partners
Goal: To reduce prevalence and
mortality from TB by half by the
year 2015 (Millennium
Development Goals)
D irectly
O bserved
T herapy
S hortcourse
A strategy!
DOTS Strategy: Elements
1. Political commitment to tuberculosis control
2. Facilities for the microscopic diagnosis of
sputum smearpositive tuberculosis
3. An uninterrupted supply of good quality anti-
tuberculosis drugs
4. Direct observation of therapy
5. Good record-keeping to facilitate assessment
of the effectiveness of the control program
Direct Observation of
Treatment
1. Who will undergo DOT? All smear (+) TB
2. Who can be treatment partner?
Staff of the health center or clinic
Member of the community such as the BHW,
local government official or former Tb
patient.
Member of the patients family (last priority)
3. Where to do DOT? in any accessible and
convenient place (RHU, home, school)
4. How long is the DOT? whole treatment
CASE FINDING
THE INDENTIFICATION AND
DIAGNOSIS OF TB CASES AMONG
INDIVIDUALS WITH SUSPECTED SIGNS
AND SYMPTOMS OF TB
DIRECT SPUTUM SAMPLE MICROSCOPY
(DSSM)
PRINCIPAL DIAGNOSTIC METHOD
CASE FINDING
DIRECT SPUTUM SAMPLE
MICROSCOPY (DSSM)

PROVIDES DEFITIVE
DIAGNOSIS
PROCEDURE IS SIMPLE
ECONOMICAL
CAN BE AVAILABLE IN
REMOTE AREAS
TB SYMPTOMATIC
(cough for 2 weeks or more)
Three (3) sputum collection
2 or 3 sputum (+) 1 smear positive all smears negative
Classify as smear-
positive TB
Collect another 3
sputum specimens
Symptoms persist, collect
another 3 sputum specimens
and refer to Medical Officer
(refer to next flow chart)
If all smear
negative
If at least one (1)
smear positive
Refer to Medical Officer
(observe pt; give symptoma-
tic treatment for 2 - 3 wks.)
Classify smear
positive TB
Request for Chest
Xray
If consistent with active TB If not consistent with active TB
Observe/further exams, if needed Classify as smear-positive TB
All 3 smears NEGATIVE
REFER to MHO
(symp. Tx for 2-3 wks)
If symptoms persist, collect another
three (3) sputum specimens
2 or 3 smear POSITIVE only one (1) smear positive all 3 smear NEGATIVE
Classify as SMEAR-
POSITIVE TB
See previous slide
CXR
Abnormal findings No abnormal findings
TB Diagnostic Committee Observation / further exam.
Consistent with active TB Not consistent with active TB
Classify as Smear-Negative TB Observation / further exam.
CLASSIFICATION OF TB
CASES
PULMONARY TB
SMEAR (+)
SPECIMEN WITH AT LEAST 2
SPUTUM (+) AFB SMEAR WITH
OR WITHOUT X RAY
ABNORMALITY
ONE SPUTUM (+) WITH
RADIOGRAPHIC ABNORMALITY
ONE SPUTUM (+) WITH
CULTURE (+)
SMEAR (-)
THREE SPUTUM (-) WITH X RAY
CONSISTENT WITH TB
EXTRA PULMONARY
TB
M.Tb (+) smear /culture from
extra pulmonary sites
Histological or clinical evidence
consistent with active extra
pulmonary tb and there is a
decision to treat
NTP Classification of TB Cases
Types* Definition of Terms
New A patient who has never had treatment for TB

or who has taken anti-tuberculosis drugs for less than
one month.

NTP TB classification
Types Definition of Terms
Relapse A patient previously treated for tuberculosis who has
been declared cured or treatment completed, and is
diagnosed with bacteriologically positive (smear or
culture) tuberculosis.
Failure A patient who, while on treatment, is sputum smear
positive at five months or later during the course of
treatment.
Return after
Default
(RAD)
A patient who returns to treatment with positive
bacteriology (smear or culture), following interruption of
treatment for two months or more.
TB classification
Types Definition of Terms
Transfer-In A patient who has been transferred from another
facility with proper referral slip to continue
treatment.
Other
All cases that do not fit into any of the above
definitions. This group includes:
A patient who is starting treatment again after
interrupting treatment for more than two months
and has remained or became smear-negative.
A sputum smear negative patient initially before
starting treatment and became sputum smear-
positive during the tx.
TB classification
Types Definition of Terms
Other
All cases that do not fit into any of the above
definitions. This group includes:
A patient who is starting treatment again after
interrupting treatment for more than two months
and has remained or became smear-negative.
A sputum smear negative patient initially before
starting treatment and became sputum smear-
positive during the tx.
Chronic case-remained sputum (+) at the end of
treatment
NTP: Outcomes of Treatment
Treatment Completed
a patient who has completed treatment but has
not met the criteria for cure or failure
A sputum smear-positive patient who has
completed treatment but without DSSM follow -
up during the treatment, or with only one negative
DSSM during the treatment, or without DSSM in
the last month of treatment.
Sputum smear negative who has completed
treatment

NTP: Outcomes of Treatment
Cure
a sputum smear-positive patient who has
completed treatment and is sputum smear
negative in the last month of treatment and on at
least one previous occasion in the continuation
phase
NTP: Outcomes of Treatment
Died
a patient who died for any reason during
the course of treatment
Transfer out
A patient who transferred to another DOTS
facility with proper referral slip for
continuation of treatment and whose
treatment outcome is not known

NTP: Outcomes of Treatment
Defaulted - a patient who interrupted
treatment for two consecutive months
or more

NTP: Outcomes of Treatment
Failed
A patient who is sputum smear-positive at
five months or later during the treatment
An initially sputum smear-negative patient
before starting treatment who becomes
smear-positive during the treatment.
(Note: This case will be re-registered as
Other with a new TB case number.)
Drug symbol Cavity Macrophage Caseation
Rifampicin R ++ + +/0
INH H ++ + +
Ethambutol E +/0 +/0 0
Pyrazinamide Z 0 ++ 0
Streptomycin S +++ 0 0
Mechanism of Action
Treatment Regimens in the
NTP
Regimen Type of TB Patient Drug / Duration of
Treatment
Regimen I
2HRZE /
4HR
New pulmonary smear (+) cases
New seriously ill pulmonary
smear (-) cases w/ extensive lung
lesions
New severely ill extra-pulmo TB
HRZE for 2 mo
during the intensive
phase.
HR for 4 mos during
maintenance phase
Regimen
II
2HRZES/
1HREZ /
5HRE
Failure cases
Relapse cases
Return after default RAD (smear
+)
Other (smear +)
HRZES for 2 mos.
then HRZE for 1 mo.
intensive phase.
HRE for 5 mos as
maintenance phase
Treatment Regimens in the
NTP
Regimen Type of TB Patient Drug / Duration of
Treatment
Regimen III
2HRZ / 4HR
New smear(-) but with minimal
pulmonary TB on radiography as
confirmed by a medical officer
New extra-pulmo TB (not serious)
HRZ for 2 mos. during
the intensive phase.
HR for 4 months as
maintenance phase
Regimen IV Chronic case
Still smear (+)after re treatment
Referred to a specialized
facility/ provincial or city
or NTP coordinator
NTP: DRUG DOSAGE ADJUSTMENT
Drug Dose per kg body weight and maximum dose
Isoniazid 5 (4-6) mg/kg, and not exceed 400mg daily
Rifampicin 10 (8-12) mg/kg, and not to exceed 600mg
daily
Pyrazinamide 25 (20-30) mg/kg, and not to exceed 2g daily
Ethambutol 15 (15-20) mg/kg, and not to exceed 1.2g daily
Streptomycin 15 (12-18) mg/kg, and not to exceed 1g daily
Regimen Type of TB Patient MONITORING
Regimen I
2HRZE / 4HR
New pulmonary smear (+) cases
New seriously ill pulmonary
smear (-) cases w/ extensive lung
lesions
New severely ill extra-pulmo TB
2 ,4, 6
Regimen II
2HRZES/
1HREZ /
5HRE
Failure cases
Relapse cases
Return after default RAD (smear
+)
Other (smear +)
3,5,8
Regimen III
2HRZ / 4HR
New smear(-) but with minimal
pulmonary TB on radiography as
confirmed by a medical officer
New extra-pulmo TB (not serious)
2
Private Public Mix DOTS
STRATEGY ADOPTED BY THE NTP
1. INCREASE CASE DETECTION
2. SYNCHRONIZE DIAGNOSIS AND
TREATMENT IN THE PRIVATE AND
PUBLIC SECTOR

Type I (Privately initiated
DOTS)
Private physician refer
patients to private DOTS
center
Drugs are provided by DOH
PUBLIC
P
PRIVATE
P

Examples:
UST Makati Med
DLSU MDH
Unilab Friendly Care
AUFMC UERM
COMPONENTS OF DOTS
PUBLIC PRIVATE
1.POLITICAL
COMMITMENT
+ +
2. DIAGNOSIS BY
SPUTUM
MICROSCOPY
+
3. SUPERVISED
TREATMENT
(DOT)
+
4.
UNINTERRUPTED
SUPPLY OF DRUG
+
5. STANDARD
REPORTING AND
RECORDING
+
COMPONENTS
PUBLIC PRIVATE
1.POLITICAL
COMMITMENT
+ +
2. DIAGNOSIS BY
SPUTUM
MICROSCOPY
+
3. SUPERVISED
TREATMENT
(DOT)
+
4.
UNINTERRUPTED
SUPPLY OF DRUG
+
5. STANDARD
REPORTING AND
RECORDING
+
Type II (Publicly initiated
DOTS)
Private physicians refer to
govt DOTS center
P
P
P
P
PUBLIC
Available in all health centers