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DipHIV > TB > Flashcards

TB Flashcards

1
Q

What ARV to start in HIV/TB coinfection?

A

Tdf/ftc plus EFV - most studied
ABC/3TC also ok but Iris and drug hypersensitivity both common may be hard to tell between the 2

RAL or DTG suitable 3rd agents but less data
Rifabutin instead of rifampicin if needing booster - only ritonavir not to use cobi with rifabutin or rifampicin

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2
Q

Dose of RAL if using with rifampicin?

A

800mg BD - REFLATE TB2 study ral 400mg bd ‘not non inferior’ to EFV

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3
Q

Dose of DTG if used with rifampicin

A

50mg BD - switch to OD 2 weeks after stopping rifampicin

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4
Q

Can doravirine be used in context of tb coinfection?

A

Possible with rifabutin only and at 100mg BD - to
Continue this for 2 weeks after dropping rifabutin

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5
Q

What tb treatment
To give if patient already suppressed on ARVs?

A

If on EFV, dtg or RAL plus 2 nucs then rifampicin and double dose dtg and ral

If on a boosted PI to use rifabutin instead
If on cobi rifabutin would need to be 150mg 3x week

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6
Q

Steroid DDI

A

Accelerated by rifamycins - increase steroid dose

Also with PI - risk of adrenal suppression

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7
Q

Methadone DDI tb tx

A

Reduced plasma levels and increased elimination with rifampicin - may need close monitoring and side effects on cessation rifampicin

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8
Q

What if patient has hep C and TB at same time?

A

Majority of patients - treat TB first then Hep C as DAA contraindicated with rifampicin

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9
Q

Definition of DILI

A

AST or ALT >3x ULN in presence of symptoms or
AST or ALT >5x ULN in absence of symptoms

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10
Q

Management of DILI

A

Consider stopping all potentially hepatotoxic drugs immediately - isoniazid, rifampicin, pyrazinamide, septrin - continue ART unless likely to cause hepatotoxicity

Check hep A, B, C serology

Ask about exposure to other hepatotoxic eg alcohol

Until cause identified treat with two or more anti tv drugs without risk of hepatotoxicity eg ethambutol, streptomycin, levo

Once ALT/AST drops below 2x ULN reintroduce as per table

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11
Q

Which drugs have highest risk of hepatotoxicity in pre existing liver disease

A

Pyrazinamide followed by isoniazid then rifampicin

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12
Q

What to do if hepatotoxicity occurs in individual with pre existing liver disease? (Rise of 2-3x abnormal baseline lfts)

A

Avoid pyrazinamide and treat with isoniazid and rifampicin for 9/12 adding ethambutol for first 8 weeks

Or avoid isoniazid and tx with rifampicin ethambutol pyrazinamide and levo for 6/12

Monitor bloods at least 2 weekly and patient to report any anorexia, nausea, vomiting, jaundice

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13
Q

GI side effects of TB treatment

A

Epigastric pain, nausea, vomiting are common especially in first 2 weeks

Try anti emetics

Can take with food (except rifampicin doses under 600mg), change timings, could switch to a regime without food restrictions if needed

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14
Q

Peripheral neuropathy

A

Occurs with isoniazid so pyridoxine co administered. can increase pyridoxine to 50mg od if peripheral neuropathy occurs.

Second line drugs need higher dose pyridoxine

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15
Q

Rash (as tx SE)

A

Most often caused by ethambutol
Occurs in first 2/12 tx

Widespread or worsening rash with systemic symptoms - stop all drugs and careful reintroduction as per table

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16
Q

Reintroduction of tb drugs after Dili or rash

A

Reintroduce all at once
If reaction occurs to all at once sequentially introduce as per table
If reaction severe or occurs again after reintroduction start with 1/10th first day dose of each drug

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17
Q

Definition of paradoxical TB IRIS

A

One major or two minor clinical criteria - no alternative explanation for deterioration

Major - new/enlarging LNs, cold abscesses, focal tissue involvement. New or worsening radiological features. New or worsening CNS TB. New or worsening serositis.

Minor - new or worsening constitutional symptoms, new or worsening resp symptoms, new or worsening abdo pain, in retrospect resolution of clinical or radiological findings without having made a change in tb tx

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18
Q

Definition unmasking IRIS

A

Major and one of two minor criteria must be met

Major - not receiving treatment when ART is started and presents with tb within 3 months of starting att

Minor - heightened intensity of clinical manifestations, once established on tb tx a clinical course that is complicated by a paradoxical reaction

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19
Q

When does TB IRIS occur?

A

Within 60 days
Median 15 days
Most individuals had advanced HIV

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20
Q

When to start ARVs in tb/hiv co infection

A

SAPIT trial

If CD4 <50 start within 2 weeks
Otherwise as soon as practically possible but within 4 weeks
Delay until 8 weeks for CNS TB

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21
Q

Symptoms of TB IRIS

A

Fever and increased or new lymphadenopathy
Dusky red skin overkykng

Need to exclude - tx failure, drug hypersensitivity, OI, malignancy

22
Q

Management TB IRIS

A

Corticosteroids - prednisolone or methylpred 1-1.5mg/kg with gradual reduction after 1-2 weeks

Rifampicin will reduce steroid effect

23
Q

Management of TB in pregnancy

A

Usual drugs at usual doses - no data to suggest teratogenic effect. Isoniazid not teratogenic even if used in first 4/12.

Increased risk peripheral neuropathy with isoniazid so increase pyridoxine

24
Q

Tx latent tb in pregnancy

A

Isoniazid recommended for pregnant women who are likely to have acquired tb recently and therefore at a higher risk of disease progression. If less risk then can be deferred until after delivery.

25
Q

Risks for babies born to mothers tx for tb in pregnancy

A

May be LBW
Need review by drs for congenital TB

Screening of household contact of mother should be completed before baby born

26
Q

Contact tracing for TB

A

CXR for asymptomatic close contacts over 65
Don’t routinely assess social contacts unless for laryngeal tb - index case has already infected someone else, social contacts immunosuppressed

27
Q

Diagnosis active TB

A

Microscopy for AFB plus culture and sensitivity
Molecular testing - XPERT MTB/RIF ULTRA - rapid confirmation TB, differentiates silent mutations from resistance conferring ones

All specimens still need full culture - liquid culture 7-28 days

28
Q

Symptoms of TB meningitis

A

Fever, headache, vomitting, gradual onset duration. Meningism, behavioural changes, alterations in consciousness

29
Q

CSF findings for TB meningitis

A

Mononuclear fell lymphocytic predominant pleocytosis in 60-85%

In advanced HIV CSF can be acellular

Low glucose (<2.5) high protein (1-5) suggestive of TBM

Culture is gold standard - AFB ZN stain - requires 6ml CSF
WHO recommends using PCR but neg result doesn’t rule out still need culture

30
Q

Classic TB histology findings

A

Epithelioid cell granulomas with or without longhand cells and cassation, necrosis and AFB

FUNGAL STAINING must always be undertaken to exclude mycosis

31
Q

MDR TB definition

A

Resistance to at least isoniazid and rifampicin

32
Q

XDR TB definition

A

Resistance to isoniazid, rifampicin and quinolones and at least one of the second line injectables eg amikacin

33
Q

How to detect drug resistant TB?

A

Routine use of whole genome sequencing of culture isolates

Routine use of PCR also

High proportion with rifampicin resistance also have isoniazid resistance so tx as MDR

34
Q

High TB incidence

A

> 151/100000

35
Q

Medium TB incidence 40-150/100000 person years

A
36
Q

To diagnose latent tb

A

People from medium to high incidence countries - IGRA and CXR

Also those from low incidence countries but with other risk factors

37
Q

What to do if IGRA result borderline

A

Repeat within 4 weeks

38
Q

What to do if IGRA pos

A

CXR and if negative tx for LTBI and if not then for tb investigations

39
Q

Treatment for LTBI

A

Daily isoniazid with pyridoxine for 6/12
Daily isoniazid with pyridoxine and rifampicin for 3/12

In certain circumstances isoniazid and rifampicin with pyridoxine twice weekly for 3/12

Balance benefit of tx against risk of hepatotoxicity of isoniazid in those with risk factors

40
Q

What should patients given isoniazid be aware of?

A

Risk of hepatotoxicity
Look out for anorexia, nausea, vomiting, abdo pain, persistent fatigue , dark coloured urine, pale stools, jaundice. Contact us urgently.

41
Q

TB treatment

A

4 drugs for 2 months, 2 drugs for 4 months

Isoniazid 5mg/kg/day 6 months
Rifampicin 10mg/kg/day 6 months
Pyrazinamide 25-35mh/kg 2/12
Ethambutol 15-20mg/kg

42
Q

TB meningitis treatment

A

Up to 12 months
Also reducing course dexamethasone IV for first 4 weeks then 4 weeks oral therapy

43
Q

Tb treatment interruption during intensive phase

A

<14 days continue and complete planned number of doses
>14 days restart tx from beginning

44
Q

Tb treatment interruption rules continuation phase

A

> 80% doses and and sputum AFB negative on initial testing - further therapy may not be necessary
80% doses and sputum was AFB pos or disease was extra pulmonary - complete course

<80% and <3/12 lapse / continue all doses until therapy completed unless consecutive lapse >2/12 and can’t be completed within 9 months then needs to restart from beginning

<80% doses and lapse >3/12 - restart from beginning

45
Q

Pre treatment testing - TB

A

Hiv cd4 and VL, lfts, u+e, fbc, how b and c, visual acuity with Snellen chart and colour vision with ishihara plates before starting ethambutol

46
Q

After how long on treatment will there be clinical improvement and negative cultures?

A

3/12

47
Q

Causes of treatment failure or relapse

A

Suboptimal prescription of or adherence to appropriate tb tx.
Presence or development of drug resistance, use of intermittent tb therapy, malabsorption of tb drugs,

48
Q

If treatment failure or relapse is diagnosed what tests should be done?

A

Drug susceptibility testing and rapid resistance testing
If too unwell to wait for result use rapid rifampicin resistance result and prev result to start a new regime

49
Q

What should patient with isoniazid mono resistant isolates be treated with?

A

Rifampicin, ethambutol, levofloxazin, pyrazinamide

50
Q

Treatment for MDR-TB

A

At least 4 active drugs all oral where possible
DOT/VOT if needed

Bedaquiline - 24 weeks - first line. Qt prolongation so caution in cardiac patients and not to use other qt prolonging drugs for 6/12 after dropping

DipHIV (19 decks)

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