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The latest DOTS regimens as of 2011
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RNTCP
Dr. Jayakumar.R MD (PULMONOLOGY)
DNB (RESPIRATORY DISEASES)
PULMONARY TB SUSPECT?
• Cough of 2 weeks or more with/without
other symptoms
• Contacts of smear-positive TB patients
having cough of any duration.
• Suspected/confirmed EPTB having cough
of any duration.
• HIV positive patient having cough of any
duration.
PULMONARY TB SUSPECT?
DIAGNOSTIC ALGORITHM
FOR
PULMONARY TB
COUGH FOR 2 WEEKS OR MORE
TWO SPUTUM SMEARS
1 or 2 POSITIVES
SMEAR + PTB
ATT
2 NEGATIVES
ANTIBIOTICS FOR 10 – 14 DAYS
COUGH PERSISTS
REPEAT 2 SPUTUM SMEARS
1 OR 2 POSITIVES
SMEAR + PTB
ATT
2 NEGATIVES
XRAY CHEST
MANTOUX
S/O TB
SMEAR - PTB
ATT
NOT S/O TB
NON-TB
TREATMENT OF TB UNDER RNTCP
WHAT IS THE MOST POTENT ANTI TB DRUG?
PAST ISONIAZID
PRESENT RIFAMPICIN
FUTURE MOXIFLOXACIN
RESEARCH TRANSITMYCIN
CLASSIFICATION OF
ANTITUBERCULAR DRUGS
TRADITIONAL CLASSIFICATION
FIRST LINE DRUGS:
INH (H)
RIFAMPICIN (R)
PYRAZINAMIDE (Z)
ETHAMBUTOL (E)
STREPTOMYCIN (S)
SECOND LINE DRUGS:
AMIKACIN, KANAMYCIN
FLUOROQUINOLONES
PAS, CYCLOSERINE
RECENT WHO CLASSIFICATION
GROUP 1 (FIRST LINE ORAL AGENTS)
• INH
GROUP 2 (INJECTABLE AGENTS)
• KANAMYCIN
GROUP 3 (FLUOROQUINOLONES)
• LEVOFLOXACIN
GROUP 4 (ORAL BACTERIOSTATIC AGENTS)
• ETHIONAMIDE
GROUP 5 (AGENTS WITH UNCLEAR EFFICACY)
• LINAZOLID, AMX-CLV
ANTI-TB DRUGS USED IN RNTCP
FIRST LINE DRUGS:
INH (H)
RIFAMPICIN (R)
PYRAZINAMIDE (Z)
ETHAMBUTOL (E)
STREPTOMYCIN (S)
SECOND LINE DRUGS:
AMIKACIN, KANAMYCIN,
FLUOROQUINOLONES,
CAPREOMYCIN,
ETHIONAMIDE
PAS, CYCLOSERINE, etc…
TREATMENT CATEGORIES
IN RNTCP
CATEGORIZATION IS BASED ON
• History of patient, including history of any previous treatment for TB
• Sputum smear examination results from an approved DMC
• Chest X-ray report if the case warrants radiographic examination
• Other supporting investigation reports, if any
FACTORS TO BE MENTIONED IN RNTCP CARD
• Disease classification
(PTB / EPTB)
• Type of case
(NEW / TREATED)
• Sputum smear result
smear + / smear --• Severity of illness • History of previous
treatment
FACTORS TO BE MENTIONED IN RNTCP CARD
• Details of X-ray
• Chemoprophylaxis for contacts aged ≤ 6 years
• HIV related data
• Treatment outcome with date
• Remarks
• CATEGORY I
• CATEGORY II
• CATEGORY III
• CATEGORY IV
• CATEGORY V
DOTS
DOTS PLUS
• NEW
-> CATEGORY I
-> CATEGORY III
• PREVIOUSLY TREATED
-> CATEGORY II
• CATEGORY IV
• CATEGORY V
DOTS
DOTS PLUS
WHAT IS DOTS ?
• DIRECTLY OBSERVED TREATMENT STRATEGY
• SHORT COURSE CHEMOTHERAPY
• INTERMITTENT REGIMEN
• INCLUDES
1. NEW
2. PREVIOUSLY TREATED
WHAT IS DOTS PLUS ?
• IN RNTCP TO ADDRESS THE MDR TB DIAGNOSIS AND MANAGEMENT
• DAILY DOT EXCEPT SUNDAY
• INCLUDES
1. CATEGORY IV
2. CATEGORY V
WHAT IS NON DOTS ?
• RARE TB PATIENTS MAY NEED NON RIFAMPICIN AND NON PYRAZINAMIDE REGIMEN
• DAILY REGIMEN
• NOT OBSERVED
• 2 SHE + 10 HE
NEW(CATEGORY I & III)
• SMEAR POSITIVE
• SMEAR NEGATIVE • EXTRAPULMONARY
• OTHERS
2(HRZE)3 + 4(HR)3
DURATION
6 MONTHS
PREVIOUSLY TREATED(CATEGORY II)
• RELAPSE SMEAR POSITIVE
• FAILURE SMEAR POSITIVE
• DEFAULT SMEAR POSITIVE
• OTHERS
2(HRZES)3 1(HRZE)3 5(HRE)3
8 MONTHS
DRUGS DOSE (THRICE A WEEK)
Isoniazid (H) 600mg
Rifampicin (R) 450mg
Pyrazinamide (Z) 1500mg
Ethambutol (E) 1200mg
Streptomycin (S) 0.75g
PEDIATRIC DOSAGE IN DOTS
ISONIAZID (H) – 10 mg/kg ( 10–15 MG/KG)
RIFAMPICIN (R) – 15 mg/kg ( 10–20 MG/KG)
PYRAZINAMIDE(Z) – 35 mg/kg (30–40 MG/KG)
ETHAMBUTOL (E) – 20 mg/kg (15–25 MG/KG)
STREPTOMYCIN (S) – 15 mg/kg
FOLLOW-UP SCHEDULE FOR SPUTUM EXAMINATION
• At the end of the intensive phase, the extended intensive phase (if applicable),
• Two months into the continuation phase and
•
• At the end of treatment.
• NEW PATIENT 0, 2, 4, 6 MONTHS
• PREVIOUSLY 0, 3, 5, 8 MONTHS TREATED
OUTCOME IN DOTS• CURED
• TREATMENT COMPLETED
• DEFAULTED
• DIED
• TRANSFERRED OUT
• FAILURE
• SWITCHED TO DOTSPLUS
MDR-TB
MULTIDRUG RESISTANT TB(MDR-TB)
MDR TB SUSPECT:
• NSP WHO REMAINS SMEAR+ @ 5 MONTHS OF RX
• NSN WHO BECOMES SMEAR+ @ 5 MONTHS OF RX
• PREVIOUSLY TREATED, SMEAR + ON 4TH MONTH
• CLOSE CONTACTS OF MDRTB PATIENTS WITH PTB+
MDR TB PATIENT:
AN MDR TB SUSPECT WHOSE SPUTUM IS CULTURE POSITIVE FOR MTB THAT ARE IN VITRO RESISTANT TO H & R WITH OR WITHOUT RESISTANT TO OTHER DRUGS FROM AN RNTCP ACCREDITED LABORATORY.
EXTENSIVELY DR TB (XDR TB)
• IN VITRO RESISTANCE TO H, R, ANY OF SECOND LINE INJECTABLE AMINOGLYCOSIDES AND ANY ONE OF FLUOROQUINOLONES.
• NO STANDARD REGIMEN AVAILABLE
• SHOULD BE TREATED ACCORDING TO CULTURE REPORTS
EXTREME DR TB / TOTAL DR TB (XXDR TB / TDRTB)
• RESISTANT TO ALL FIRST- AND SECOND-LINE DRUGS
• TILL NOW NO TREATMENT AVAILABLE (possible)
CATEGORY IV (DOTS PLUS)
• MULTI DRUG RESISTANT TB (MDR TB)
• RIFAMPICIN MONORESITANCE
REGIMEN6(9) Km Lvx Eto Cs Z E
FOLLOWED BY 18 Lvx Eto Cs E
DURATION24 – 27 MONTHS
CATEGORY V (DOTS PLUS)
• EXTENSIVELY DRUG RESISTANT TB (XDR TB)
REGIMEN6(12) INTENSIVE PHASE FOLLOWED
BY 18 CONTINUATION PHASE
(Cm, PAS, Mfx, Cfz, Lzd, Amx/clv, Clr, Thz)
DURATION
24 -- 30 MONTHS
SUMMARY
SUMMARY
DIAGNOSIS OF PTB
• DURATION OF COUGH
3 WEEKS 2 WEEKS
• NUMBER OF SPUTUM SMEARS TO BE COLLECTED
3 SMEARS 2 SMEARS
• NUMBER OF + SMEARS REQUIRED FOR DX OF PTB+
2 SMEARS 1 SMEAR
• CATEGORY III HAS BEEN PHASED OUT
• NEW (DOTS)
• PREVIOUSLY TREATED (DOTS)
• CATEGORY IV FOR MDRTB
• CATEGORY V FOR XDRTB
SUMMARY
TREATMENT OF PTB