Tuberculosis

By: Alfredo De Ocampo Jr.,MD PWU - College of Pharmacy

 Tuberculosis (TB) remains the leading cause of death

worldwide from a single infectious disease agent. Indeed up to 1/2 of the world's population is infected with TB. The registered number of new cases of TB worldwide roughly correlates with economic conditions: the highest incidences are seen in those countries of Africa, Asia, and Latin America with the lowest gross national products. WHO estimates that eight million people get TB every year, of whom 95% live in developing countries. An estimated 2 million people die from TB every year.

 It is estimated that between 2000 and 2020, nearly one

billion people will be newly infected, 200 million people will get sick, and 35 million will die from TB - if control is not further strengthened. The mechanisms, pathogenesis, and prophylaxis knowledge is minimal. After a century of decline TB is increasing and there are strains emerging which are resistant to antibiotics. This excess of cases is attributable to the changes in the social structure in cities, the human immunodeficiency virus epidemic, and failure of most cities to improve public health programs, and the economic cost of treating.

 TB is an ancient infectious disease caused by

Mycobacterium tuberculosis. It has been known since 1000 B.C., so it not a new disease. Since TB is a disease of respiratory transmission, optimal conditions for transmission include:
overcrowding poor personal hygiene

poor public hygiene

 With the increased incidence of AIDS, TB has

become more a problem in the U.S., and the world.

It is currently estimated that 1/2 of the world's

population (3.1 billion) is infected with Mycobacterium tuberculosis. Mycobacterium avium complex is associated with AIDS related TB.

Transmission
Pulmonary tuberculosis is a disease of respiratory

transmission, Patients with the active disease (bacilli) expel them into the air by:
coughing, sneezing, shouting, or any other way that will expel bacilli into the air

 Once inhaled by a tuberculin free person, the

bacilli multiply 4 -6 weeks and spreads throughout the body. The bacilli implant in areas of high partial pressure of oxygen:
lung
renal cortex reticuloendothelial system

 This is known as the primary infection. The patient will

heal and a scar will appear in the infected loci. There will also be a few viable bacilli/spores may remain in these areas (particularly in the lung). The bacteria at this time goes into a dormant state, as long as the person's immune system remains active and functions normally this person isn't bothered by the dormant bacillus.
When a person's immune system is depressed., a

secondary reactivation occurs. 85-90% of the cases seen which are of secondary reactivation type occurs in the lungs.

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Classification of Drugs
3 Groups depending upon the degree of

effectiveness and potential side effects

First Line: (Primary agents) are the most effective and have lowest toxicity. Isoniazid Rifampin Second Line: Less effective and more toxic effects include (in no particular order): p-amino salicylic acid, Streptomycin, Ethambutol Third Line are least effective and most toxic. Amikacin, Kanamycin, Capreomycin, Viomycin, Kanamycin, Cycloserine

Isoniazid
Considered the drug of choice for the chemotherapy of TB.

discovered in 1945 a hydrazide of isonicotonic acid

is bacteriostatic for resting bacilli, bactericidal for growing bacilli.

Mechanism of action
Unknown, but the hypothesis include effects on lipids,

nucleic acid and biosynthesis.

Primary action seems to inhibit the biosynthesis of

mycolic acids which are part of cell wall structure.

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Resistance
Organism eventually develops resistance.

The mechanism of resistance is related to the

failure of the drug to penetrate or be taken up by the micro-organism (by active transport system),
Remember treatment is up to 2 years.

Pharmacokinetics
Absorption: INH rapidly absorbed either oral or

parenteral route. Peak [plasma] of 3-5 micrograms/milliliter after oral administration.

Distribution: Diffuses readily into all bodily fluids does not bind to plasma proteins In the CSF the [conc] is about 20% of [plasma], t1/2 =1-3 hrs.

Excretion
75-95% of a dose excreted in the urine in 24 hr.

- Mostly as a metabolite.
- The main excretory product- acetylisoniazid.

This is a result of enzymatic acetylation, Very important in terms of metabolism, Isoniazid is under genetic control, There are 2 groups of people. Fast and slow acetylators

Excretion cont.
Those that have slow acetyl transferase activity are

slow acetylators, may produce more of the toxic intermediate.

This is an inherited trait ==> Autosomal Dominant The average [plasma] will be (1/3) to (1/2) of the

slow acetylators Average t1/2, is less than 90 minutes, in the slow acetylators, t1/2 will be about 3 hours.
Ethnicity- Eskimos,Native American Indians, and

Asians are fast aceytlators,

Adverse Effects
Induced Hepatitis (2% of Population) due to the

buildup of toxic metabolic products of acetylisoniazid --> acetylhydrazine. This is more frequent in slow acetylators.
Hepatic reactions to Isoniazid are also age

dependent
There is a 250X increase in the incidence of hepatitis

over age. More frequent in the fast acetylators when measured intragroup, (Compare elderly fast acetylators patients with elderly slow patients,) Ranges from mild hepatitis to serious tissue necrosis.

Age dependency
% incidence 0.13 .59 age 25 35

1.09
1.75

45
55

2.5

>60

 Patients with renal failure, the normal dose can be

given, because it is secreted in the inactive form.

Patients with hepatic insufficiency - give a reduced

dose of the drug.

ETOH causes induction of drug metabolizing

enzymes, Isoniazid is broken down faster. Leads to lsoniazid hepatotoxicity.

Glucose 6- Phosphate deficiency. People with a

deficiency of Glucose-6-phosphate cannot adequately process the drug.

Drug Interaction
Competition between Isoniazid and Phenytoin

(anticonvulsant). They both compete for drug metabolism enzymes. Phenytoin interferes with metabolism of isoniazid by reduction in excretion or enhancement of effect of isoniazid

Rifampin
Mechanism of Action
Rifampin inhibits DNA dependent RNA polymerase of the

bacilli.

Resistance:
Due to alteration of the target (DNA dependent RNA

polymerase) of the drug, prevents further initiation but not elongation. The micro-organism can change the structure of the enzyme so that the drug no longer has an effect.

Pharmacokinetics
Absorption

peak levels reached 2-4 hrs. after oral dose

rapidly eliminated in the bile and reabsorbed

(enterohepatic circulation) It can be delayed with use of aminosalicylic acid.

during this time there is a progressive

deacylation of the drug;

the metabolites maintain full effect Half life is 6 hours.

 Distribution:

Throughout the total body water

Present in effective concentrations in many

organs and body fluids including CSF,

With Rifampin you must warn patients: The drug

has an orange red color in body excretions, This color will be imparted to all body fluids.

Adverse Effects:
Does not cause many side effects in any great frequency. G.I. reactions: Anorexia, Nausea ,Vomiting Mild

abdominal pain, Hepatic Reactions in children, pregnant women and alcoholics, can result in minor elevations in serum transaminase as some jaundice

 Allergic Reactions
Fever Skin Eruptions Rash Pruritis

Rifampin does induce microsomal drug

metabolizing enzymes. This will decrease the half-life of some other drugs. (ie. phenytoin, digitoxin)

WARNING!
Rifampin and Isoniazid are the most effective drugs for the treatment of TB, The drug enjoys high patient compliance and acceptability. But these 2 drugs should never be given alone! They are always used in combination because resistance occurs to one drug alone very rapidly. They are used in combination with each other initially as well as other drugs. Bacilli must become resistant to two drugs in order to remain viable. Statistically, the chances are verv small of the bacilli becoming resistant to both. . Prophylaxis is with one drug usually isoniazid.

2nd Line Drugs: Not as effective and have more toxicity

Streptomycin
The first drug used clinically for treatment of TB

1947-1952; was the only drug available at that time.

is an aminoglycoside antibiotic acts by protein synthesis inhibitor and decreases

the fidelity mRNA and garbles the message, leads to nonsense proteins.
Streptomycin only binds to the 30s subunit.

 Adverse Effects:

affects C. Nerve 8: auditory and vestibular functions. -

this drug is now 2nd 'line because of its toxicity.

para- Aminosalicylic Acid

a structural analog of PABA (p-aminobenzoic

acid) is bacteriostatic inhibits de novo folate synthesis

half life = 1 hour after 4 g. dose

you can give this drug up to 12 grams per

day. 80% of the drug is excreted in the urine and 50% of that is as an acetylated metabolite which is insoluble. You must make sure the patient's urine is normal or alkaline.

Adverse effects
GI irritation due to the amount of drug given

(high doses) nausea, vomiting, bleeding, occurs in 30-40% of the patients. be careful with those who have peptic ulcers
hepatotoxicity

Hypersensitivity reactions Rash, Fever some All will disappear when the drug is stopped

This drug has poor patient acceptability and

compliance:

Third Line Drugs - least effective and

most toxic
Third line drugs are used when resistance is developed to

1st and 2nd line drugs; these drugs are also used in combination.
Aminoglycosides Capreomycin - Viomycin - Kanamycin

Adverse effects
These drugs are: Nephrotoxic - will cause Proteinuria,

Hematuria, Nitrogen metabolism, and Electrolyte disturbances However effect is reversible when drug is stopped.

 Ototoxic will result in deafness and some loss of

vestibular function, leads to cranial nerve 8 damage. The nerve damage is permanent.
Capreomycin has replaced viomycin because of less

toxic effects, but all three drugs have the same effects.

Cycloserine
can cause CNS disturbances Therapeutic States

Cycloserine should be used when re-treatment is necessary or when the micro-organism is resistant to the other drugs.
It must be given in combination with other anti-

tuberculosis drugs.

Mechanism of Action:

An analog of D-alanine synthetase, will block bacterial cell wall synthesis.

 Pharmacokinetics: Rapidly absorbed Peak [plasma]

occurs in 3-4 hours Distributed throughout all body fluids, including CSF About 50% is excreted in unchanged form in the urine during the first 12 hours. Only about 35% of the drug metabolized This drug can accumulate to toxic conc in patients with renal insufficiency

 Toxicity:

Most common in the CNS: Headache, Tremor, Vertigo,

Confusion, Nervousness, Psychotic states with suicidal tendencies , Paranoid reactions, Catatonic and depressed reactions

Chemoprophylaxis of TB
Used only in high risk groups
Household members and other close contacts of a patient

with active TB.

A positive skin test in persons less than 35 years. A positive skin test reactive in the immunosuppressed,

persons with leukemia, and Hodgkin's Disease,

HIV + patients with a positive TB test,

 The drug of choice for chemoprophylaxis is

isoniazid. Prophylaxis uses only one drug. In patients who are HIV+ and TB+ and have the disease; they are treated for a minimum of 9 months, The first 2 months using isoniazid and rifampin and for the next 7 months or longer, use only 2 or 3 of the 2nd/3rd line drugs and Isoniazid/Rifampin.

Chemotherapy of TB
Most patients are treated in an ambulatory setting -

admitted to the hospital - diagnosis is established initiate and stabilize therapy - send patient home , usually after 2 or 3 weeks
First and second line agents are usually given orally.

Third line drugs are given parenterally.

Treatment
Isoniazid, Ethambutol, & Rifampin are given for 2

months.
Isoniazid & Rifampin are given for 4 months.

If you suspect resistance to isoniazid use Isoniazid,

Ethambutol, Rifampin & Parazinamide. Incidence of drug resistance is 2-5% in the U.S.
Prolonged bed rest is not necessary or helpful in

obtaining a speedy recovery. The patient must be seen at regular and frequent intervals to follow the course of the disease and treatment. Look for toxic effects

Antitubercular Agents
Tuberculosis, TB

Caused by Mycobacterium tuberculosis

Antitubercular agents treat all forms of mycobacterium

Mycobacterium Infections
Common Infection Sites
lung (primary site)
brain bone liver kidney

Mycobacterium Infections
Aerobic bacillus

Passed from infected:

Humans Cows (bovine)

Birds (avian)

Mycobacterium Infections
Tubercle bacilli are conveyed by droplets. Droplets are expelled by coughing or sneezing,

then gain entry into the body by inhalation.

Tubercle bacilli then spread to other body organs

via blood and lymphatic systems.

Tubercle bacilli may become dormant, or walled

off by calcified or fibrous tissue.

Antitubercular Agents
Primary Agents isoniazid* Secondary Agents capreomycin

ethambutol
pyrazinamide (PZA) rifampin streptomycin
*most frequently used

cycloserine
ethionamide kanamycin para-aminosalicyclic acid (PSA)

Antitubercular Agents: Mechanism of Action

Three Groups
Protein wall synthesis inhibitors streptomycin,

kanamycin, capreomycin, rifampin, rifabutin

Cell wall synthesis inhibitors cycloserine, ethionamide,

isoniazid
Other mechanisms of action

Antitubercular Agents: Mechanism of Action isoniazid (INH)

Drug of choice for TB Resistant strains of mycobacterium emerging Metabolized in the liver through acetylationwatch

for slow acetylators

Antitubercular Agents: Therapeutic Uses

Used for the prophylaxis or treatment of TB

Antitubercular Therapy
Effectiveness depends upon:
Type of infection Adequate dosing Sufficient duration of treatment Drug compliance Selection of an effective drug combination

Antitubercular Agents: Side Effects

INH

peripheral neuritis, hepatotoxicity

ethambutol

retrobulbar neuritis, blindness

rifampin

hepatitis, discoloration of urine, stools

Antitubercular Agents: Implications

Obtain a thorough medical history and assessment. Perform liver function studies in patients

who are to receive isoniazid or rifampin (especially in elderly patients or those who use alcohol daily).
Assess for contraindications to the various agents,

conditions for cautious use, and potential drug interactions.

Antitubercular Agents: Implications

Patient education is CRITICAL:
Therapy may last for up to 24 months.
Take medications exactly as ordered,

at the same time every day.

Emphasize the importance of strict compliance

to regimen for improvement of condition or cure.

Antitubercular Agents: Implications

Patient education is CRITICAL:
Remind patients that they are contagious during

the initial period of their illnessinstruct in proper hygiene and prevention of the spread of infected droplets.
Emphasize to patients to take care of themselves,

including adequate nutrition and rest.

Antitubercular Agents: Implications

Patients should not consume alcohol while on these

medications nor take other medications, including OTC, unless they check with their physician.
Diabetic patients taking INH should monitor their

blood glucose levels because hyperglycemia may occur.

INH and rifampin cause oral contraceptives to

become ineffective; another form of birth control will be needed.

Antitubercular Agents: Implications

Patients who are taking rifampin should be told that their

urine, stool, saliva, sputum, sweat, or tears may become reddish-orange; even contact lenses may be stained.
Vitamin B6 may is needed to combat peripheral neuritis

associated with INH therapy.

Antitubercular Agents: Implications

Monitor for side effects
Instruct patients on the side effects that should be

reported to the physician immediately.

These include fatigue, nausea, vomiting, numbness and

tingling of the extremities, fever, loss of appetite, depression, jaundice.

Antitubercular Agents: Implications

Monitor for therapeutic effects:
Decrease in symptoms of TB, such as cough

and fever
Lab studies (culture and sensitivity tests)

and CXR should confirm clinical findings

Watch for lack of clinical response to therapy,

indicating possible drug resistance