ESCMID Online Lecture Library. by author

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1 Palliative care of patients with drug-resistant tuberculosis MD, PhD Kutsyna Galyna Luhansk State Medical University, Ukraine

2 Palliative care WHO definition "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering MDR-TB palliative treatment care goals: symptom management during acute, chronic disease and end-of-life care providing holistic, social and spiritual care

3 When palliative care should start in MDR-TB treatment? TB palliative care should be incorporated into each step of care from disease presentation through to end of life care

4 MDR-TB and palliative treatment issues MDR-TB chemotherapy drugs + palliative care drugs polypharmacy possible interaction with MDR -TB chemotherapy: medications that interfere with TB drugs absorption antacids containing aluminium or with TB drugs, particularly with isoniazid and fluoroquinolones magnesium selectively compete search for optimal treatment modalities modifications choice of drugs and therapy duration when MDR-TB combined severe co-morbid conditions as liver disease, renal failure decreasing TB drugs dose as a toxicity symptom management suboptimal concentration triggering drug resistance

5 One of the main palliative care goals MDR-TB symptoms management Acute or chronic pain Cough and difficult breathing Hiccups Fever Peripheral oedema or swelling of limbs Depression anxiety and agitation Dementia or delirium Trouble sleeping Pain on swallowing Ulcers Diarrhea Constipations Nausea and vomiting Itching Bedsores

6 Pain control The cause identification: Inflammation due to TB infiltration of the lung, pleura or other internal organs Muscle strain due to excessive coughing Muscle cramps and spasms due to potassium wasting (injectable drugs, particularly capreomycin) Bone pain from TB infiltration into the spine or bone Joint pain from gout (precipitated by Pyrazinamide ) or septic arthritis Painful feet: Drug induced peripheral neuropathy (isoniazid or ARVs). Symptoms management Mild pain: Paracetamol 2x 500 mg tabs 4-6 hourly Moderate pain: Codeine phosphate mg 4 hourly Severe pain: Morphine sulphate 5-10 mg 4 hourly Bone pain: Ibuprofen mg 8 hourly Neuropathic pain: Vit B6 100mg and Amitryptiline 25 mg daily

7 Nausea and Vomiting Nausea and vomiting in TB patients can have a wide variety of causes and it is important identify the specific one. Most common Side effect of TB drugs: Isoniazid, Rifampicin or Pyrazinamide may cause hepato-toxicity (clinically signs of jaundice and elevated liver enzymes). Ethionamide has a direct toxic effect on the stomach lining and nausea is usually immediate, PAS toxicity is usually more delayed. Side effect of ARVs, consider lactic acidosis if together with short of breath (d4t)- check for lactate level Intoxication caused by opportunistic Infections or complications such as IRIS Raised intracranial pressure or meningitis, if there also other signs of meningitis as severe headache Symptoms management After the above conditions have been excluded: Metoclopramide 10mg 8 hourly for a day or two and then review. TB drugs should ideally be taken on an empty stomach but in some cases of troublesome nausea and vomiting a light meal may be given beforehand for a day or two to see if the drugs are better tolerated. Ethionamide and PAS daily dose should be given in two times, both have dose-dependent side effects, decreasing the dose will alleviate the symptoms.

8 Cough or difficult breathing Control bronchospasm β2 receptor agonist: Sulbutamol by metered dose inhaler with spacer or mask Next if there no contraindications prednizolone mg daily for 5-7 day Relive excessive sputum If cough with thick sputum steam inhalators If more them 30ml per day expiratory technique: huffing with postural drainage For bothersome dry cough If an opioid not already been used, give codeine phosphate 30 mg 4 times daily if there no response give oral morphine 2,5-5mg To alleviate shortness of breath oxygen inhalation End of the life care small dose morphine can reduce dysponea Under Monitoring respiratory rate for signs of respiratory depression: For patients not on morphine to pain relief give morphine phosphate 25mg - every four hours For patients already in morphine increase the dose on 25% if it does not work on increase on another 25 % To relieve symptoms of heart failure and to treat pitting oedema - furosemide 40 mg daily To relieve anxiety or teminal agitation diazepam

9 may be caused by PAS Persistent diarrhoea In HIV-positive the patients consider chronic infectious diarrhoea; empirical treatment alcohol's effect on the pancreas and liver in alcohol abuse patients, Symptoms management: Increasing the patient s fluid intake to prevent dehydration. Give oral rehidration solution if there is a large volume of diarrhoea Prescription constipating drug unless there is blood in the stool or fever is present or if the patient is elderly Supportive diet for patients with diarrhoea

10 Depression, anxiety or psychosis There are many causes of depression and anxiety in patients with MDR-TB: prolonged sickness, separation from family or lack of family support, difficult living conditions holistic needed to be provided. Caused by Medication: If due to EFZ, consider switching to NVP Severe depression, anxiety or psychosis is usually due to terizidone or cycloserine. Symptoms include:panic attacks, hearing voices or seeing things that do not exist, paranoia, coma. Supportive care: Symptoms usually improve when the dose of cycloserine is decreased. Cycloserine should stop immediately if the become suicidal or psychotic. Mild depression can be managed with amitryptiline at night.

11 Nutritional support Encouraging patients for small frequent meals and drinks until the patient s appetite returns Vit B or Vit B included polyvitamins complex Оral potassium and magnesium supplements Special care for patients who are undernutrition and anaemia Nutritional supplements

12 MDR-TB treatment outcomes for surviving patients TB chemotherapy + palliative care TB cure treatment completion TB chemotherapy + palliative care default, fail palliative care only?

13 When MDR-TB therapy should stop? It is clear that TB palliative care should be incorporated into each step of care from disease presentation through to end of life care and unclear when patients should be under TB palliative care only

14 For whom MDR-TB therapy should stop or don t start??? For whom TB treatment should don t start? likely to die within the next 2-3 weeks via respiratory distress, severe wasting syndrome, neuro TB, acute renal/hepatic failure Patients whose TB does not respond to treatment requires consideration of whether to stop TB treatment, and where individuals should receive end-of-life palliative care Decision on termination of MDR-TB treatment: - should made by consulting team - patient s choice about continuation or stop therapy should be taken to the consideration too

15 Where patients with MDR-TB should receive end-of-life palliative care Community-based treatment: programmes in Peru, Lesotho and other setting multidisciplinary teams delivering care to the person with MDR-TB within his own home. Palliative care is also provided. Hospitalization: in many industrialised countries and some poor and middle-income countries as Ukraine - strict hospitalisation for culture positive patient at least until the case becomes culture-negative. Palliative care should also provided in hospitals. Special places are need for specific cohort of patients, who are on palliative care only.

16 Lisichansk TB palliative care hospital This TB palliative care hospital was based on local MDR-TB dispensary in There is 564 patients with MDR-TB have been receiving the TB palliative care for the next two years, 136 of them died. The hospital s goals: Social defense and epidemiological isolation patients with poor TB prognosis.

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19 What is the burden have the TB palliative care hospital s staff expose to a high risk environment for TB infection apart of medical care there is a necessity of providing the psychological care for patients (no one clinical psychologist are employed for this specific care) communication often with terminally ill patients, patients with asocial behavior burnout syndrome The balancing between the patient s rights and responsibility for patient s epidemiological isolation

20 What is the burden patients have before coming to palliative care hospital TB process in both lungs: chronic fibro-cavitary TB disseminated TB respiratory deterioration: breathlessness, respiratory failure HIV/AIDS other severe co-morbid diseases: a liver or kidny insufficiency, diabetes, heart disease (problem with administration the second and third line drugs) sequences of social stigmatization and long months of isolation lack of home and family distressing symptoms asocial behavior drugs /alcohol addiction

21 Patients cohort in Lisichansk TB palliative care hospital, Ukraine Patients distribution according to their MDR-TB treatment status: Refused TB treatment (1-3%) Poor adherence (70-80%) treatment default (repeated interruption of treatment more then 2 months) consistent multiple interruption of treatment for few days Do not respond to treatment (20-30%) treatment failure (2/5 culture positive collection during 2nd year of treatment) failure of re-treatment regimenes/chronic TB patients (sputum positive at the end of the intensive phase and on completion of re-treatment regime) Do not tolerated treatment patients with acute or chronic polyorgan insufficiency, who could not tolerate MDR-TB chemotherapy toxicity anymore (up to 40%) terminally ill patients (1-3%)

22 % of patients TB palliative care after MDR-TB chemotherapy termination not always means end-of-life care patients 10 53, 66, 91 months months on palliative treatment 65% 65% 35% 35% Study design: Survival after MDR-TB chemotherapy termination was analyzed in 100 consecutive patients under palliative treatment, who discharged/ died backward March 31,2013

23 The long term (years) survives MDR- TB patients after the TB treatment termination are important targets to study Patient s phenotype Phenotypic Features of Strains Mycobacterium tuberculosis they are infected with Specific and innate immune response features to Mycobacterium tuberculosis

24 Global MDR -TB challenge requires Global solution Library Lecture TB drugs are tools to cure TB but this treatment also results of selection of resistant mutants in the TB mycobacterium population due to killing susceptible bacilli strains It is clear that cases of MDR/ XDR-TB are on the rise in the world Online TB patients cohort needs in palliative treatment will grow up with time ESCMID The special places are need for those who are terminally ill, homeless and hopeless. 1

25 According to WHO TB is considered to be a curable infection but it is one of leading causes of deaths in the world Today TB became worse as a problem due to spread MDR-TB and TB with HIV where current treatment are toxic and effective only in half of cases what to do with other half..?

26 I m still very much influenced by my background as a doctor and clinician and so want to see we can support countries and governments to care for people, not just cure pieces of lungs that happen to be sick, but to look at the individual. It s difficult to come out with these ideas in an environment where things are so focused on outcomes, how many people cured, how many DOTS programmes are [being created]. But how about all the people, how about those that we are not curing? What are we doing to provide for these people and families and relatives with decent care and not just delivering pills? Dr Ernesto Jaramillo of WHO s STOP TB

27 Dr. Galyna Raenko Head of Luhansk reagional TB hospital, Ukraine Dr. Nathalya Prihoda Acknowledgment Head of Lisichansk TB palliative care hospital, Ukraine Dr. Yuriy Ephremenko Lisichansk TB palliative care hospital, Ukraine