Simple Review treatment of TB and HIV

Thai Regimens

Sathienwit Rowsathien, MD.

TB

• Directly Observed Therapy (DOT) is key…– Self-administered is not DOT!

• Only single dose per day– TB replication times is over 24 hrs period.

TB Catergory

• CAT I – Newly diagnose patient with TB smear +ve– Seriously ill with extra pulmolnary TB, Parenchymal TB– 2HRZE:4HR

• If smear +ve at 2 month, add 1HRZE (total 3HRZE) and repeat smear at 3 month + DST

• 7HR if smear +ve at 3 month, meningitis, disseminated or spinal bone or joint complication.

• CAT II– Relapse, Failure, After default– 2HRZES:1HRZE:5HRE

• If smear +ve at 3 month, add 1HRZES (total 4HRZES) and repeat smear at 4 month + DST

TB Catergory

• CAT III– TB smear –ve (thx 3 times ) – Minor extra pulmonary TB (TB lymphadenitis)

• 2HRZ:4HR

• CAT IV– Chronic TB

• Combination of reserved drugs.• Consult ID specialists• May classified as MDR:TB, XDR:TB :( • 6 months initiation, 18 months continuation phase.

TB Drugs in Thailand (combine)

• RIMSTAR/RIFAFOUR per 1 tablet– H 75 mg (I)– R 150 mg– Z 400 mg– E 275 mg

• RIMACTAZID per 1 tablet– H 75 mg (I)– R 150 mg

• RIFINAH 150/300– H (100) R (150)– H (150) R (300)

TB Drugs

S may be no more than 750mg/day in old age (60+)

TB Drugs

HIV

• HAART when CD4 <350– 2NRTI+1NNRTI, or 2NRTI+1PI

• If TB coexists– CD4 <350 start HAART within 2 weeks after start Anti-TB– CD4 >350, wait for cure TB – Common Regimen as 3TC+d4T+NVP or 3TC+AZT+NVP

• Start Anti-TB as CAT I is appropriated.

– If HAART include Efavirenz or 2nd line drugs, consult ID first.

HIV

HIV Thai regimen• Usually initiate with 3TC+AZT+NVP (AZT long

term SE less than d4T) except– Severe anemia (Hb<8.4)– CD4 > 100– Low BW• May initiate with GPOVir S30 (d4T) but no more than 6

month then switch to GPOVirZ (AZT) (and viral load must <50copies/ml)

HIV Thai regimen

• Lead in NVP in 1st 2 weeks (Prevention SJS)– NVP(200) 1 dose per day in 1st 2 weeks– Ex. GPOVirZ 1 tab in the morning, 3TC+AZT (Zilarvir no

NVP) before bedtime.

• If no SJS, no hepatitis (liver enzyme not exceed more than 5x base line) , continue NVP full dose – (NVP(200) 1 tab o q 12 hr), GPOs30 or GPOvirZ 250 BID

HIV Thai regimen

• EFV-based regimen– For NVP Failure– EFV OD HS, 3TC+AZT (or D4T) q 12 hr– Common SE is insomnia, nightmare (improve

within 2 weeks after initiate)

HIV Thai regimen

• PI-based regimen– Poor tolerance in NNRTI based regimen– d4T + 3TC + IDV + RTV (all bid)• IDV SE: non opaque stone, pt. must drink 1.5-2 L of

water/day

Common NRTI SE

• d4T– Peripheral neuropathy– Hyperlactatemia (beware of high gap acidosis)– Lipodystrophy– Dyslipidemia

• AZT– BM suppression– GI irritation– Headache and myopathy

Common NRTI SE

• ddI– GI irritation– Pancreatitis– Peripheral neuropathy (in comb with d4T)

• 3TC– Low SE

Common NNRTI SE

• NVP– SJS– Hepatitis

• EFV– Neuropathy– Dyslipidemia

Common PI SE

• IDV– Decrease GFR– Non opaque stone

HAART Failure

• Virological failure– Viral load > 1,000 copies/ml in 6 month after initiation of

HAART

• Immunological failure– CD4 increase <50 cells/mm3 in 1st year– CD4 decrease after peak more than 30%

• Clinical failure– OI (except TB)

References คร่�าวๆ• CDC• WHO• โร่งพยาบาลยะหร่��ง• สำ�านั�กแพทย� กทม.• KKU• Google