NTNC Membership Opportunities NTNC MEMBERSHIP DRIVE WEBINAR. Juggling TB and Alcoholism. Nurse Case Management of the TB Patient April 14, 2016

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1 NTNC MEMBERSHIP DRIVE WEBINAR It s Never Just TB Juggling TB and Alcoholism Nurse Case Management of the TB Patient April 14, 2016 National Tuberculosis Nurse Coalition The mission of the NTNC is to advise and support the TB control officials of state, local, and territorial governments by providing, within NTCA, a coordinated nursing perspective on issues vital to the success of TB prevention and control programs. NTNC Membership Opportunities Membership is tied to NTCA Any member of the NTCA can select to be a member of the NTNC section if Nursing background and education Current/previous position in TB nursing Interested in TB nurse case management Desire to be involved with a group of active individuals who share a professional identity 1

2 Membership Information January is the time to renew your membership in NTCA and NTNC! Individual Membership is still just $55 per year and includes: Reduced registration for the annual National TB Conference Reduced prices on NTCA/NTNC products, e.g., Comprehensive TB Nursing Manual Participation in NTCA or NTNC Member Only events Subscription to the e newsletter New in 2015 and 2016 Expanded membership opportunities Institutional Program Membership (2015) TB controller and 4 others (Program must be directly funded by CDC co ag) Local Institutional Program Membership (2015) TB controller and 4 others (Programs not directly funded by CDC co ag) Additional members to an institutional membership can join for only $25! (new in 2016) Check with your TB controller to see if your program or health department has taken advantage of this institutional membership! Benefits of NTNC Membership Collective voice for TB Nurses Forum for exchange of ideas with other TB Nurses Presentations for members only Archived presentations for members only Professional home for nurses working in TB Networking with a great group of people! 2

3 Join or Renew Now! To renew your NTCA/NTNC membership, or to join for the first time, Go to and complete the online application Call the NTCA office and complete the application over the telephone Question and Answer Chat Feature within the webcasting platform Find the Q&A box on your screen Type in your question or comment and hit send to submit to the Moderator Questions will be answered AFTER the presentation, but you may submit them at any time. TB and Alcohol Use Disorder Webinar Charlie Bark, MD Medical Director Katie Emanuel DeJoy, RN Nursing Director Cuyahoga County TB Program MetroHealth Medical Center Cleveland, Ohio April 14,

4 Disclosures None No financial conflicts Objectives 1. Describe what is known about the relationship between alcohol use disorder and the risk of tuberculosis. 2. Discuss the challenges in the management of tuberculosis in people with alcohol use disorder. 3. Review strategies to prevent tuberculosis in those with alcohol use disorder and latent tuberculosis infection. 4. Review TB Cases involving alcohol use disorder 5. Review alternative TB regimens when treating TB patients with alcohol use disorder Objective 1 Describe what is known about the relationship between alcohol use disorder and the risk of tuberculosis 4

5 Alcohol and TB: The History Alcohol and TB: The Science Alcohol Res Health. 2010; 33(1 2): Alcohol and TB: The Practical Alcoholic patients suffer from a disease where alcohol consumption is their priority, and judgement if often impaired TB treatment is usually not a priority Lack of buy in, lack of adherence Often concurrent liver disease and increased hepatotoxicity risk 5

6 DSM 5 Alcohol Use Disorder (AUD) AUD replaces alcohol abuse and alcohol dependence Alcohol Use Disorder: Criteria 1. Recurrent drinking resulting in failure to fulfill role obligations 2. Recurrent drinking in hazardous situations 3. Continued drinking despite alcohol related social or interpersonal problems 4. Evidence of tolerance 5. Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal 6. Drinking in larger amounts or over longer periods than intended 7. Persistent desire or unsuccessful attempts to stop or reduce drinking 8. Great deal of time spent obtaining, using, or recovering from alcohol 9. Important activities given up or reduced because of drinking 10. Continued drinking despite knowledge of physical or psychological problems caused by alcohol 11. Alcohol craving AUD: Severity Mild: Two to three symptoms Moderate: Four to five symptoms Severe: Six or more symptoms 6

7 Alcohol Use Disorder in the U.S. JAMA Psychiatry. 2015;72(8): Alcohol use in the U.S. In the past 30 days: 52% had at least 1 drink 23% binge drink 6% drink heavily 2011 US National Survey on Drug Use and Health CDC Study: TB and Alcohol in the U.S. CDC Study of 207,307 TB patients Int J Tuberc Lung Dis. 2015;19:

8 CDC: TB and Alcohol in the U.S. Prevalence of Excess Alcohol Use Int J Tuberc Lung Dis. 2015;19: CDC: TB and Alcohol in the U.S. Risk Factors CDC: TB and Alcohol in the U.S. States Int J Tuberc Lung Dis. 2015;19:

9 CDC: TB and Alcohol in the U.S. Time to Culture Conversion Int J Tuberc Lung Dis. 2015;19: CDC: TB and Alcohol in the U.S. Excessive alcohol use is seen in about 15% of TB patients Time to culture conversion to negative is prolonged Rates of death and loss to follow up are significantly higher Objective 2 Discuss the challenges in the management of tuberculosis in people with alcohol use disorder 9

10 Case 1: M.C. 53 y.o. man with R lung and pleural TB History of AUD: Drinks 6 7 beers per day, no known cirrhosis Could not remember when he became sick Sister found him sick and brought him to the hospital where he was diagnosed and started on TB treatment Case 1: M.C. Treatment Course Discharged to Sister s house, DOT continued 10 days later his Sister says he disappeared He has no cell phone, no address Next day presented to a local ED Case 1: M.C.: Treatment Course Continued ED called, said he was being discharged to Sister He did not show up, could not be found for 2 weeks Then presented to Metro ED after a fall (due to alcohol intoxication) at a homeless shelter, dx d with hip fracture 10

11 Case 1: M.C. Treatment Course Continued Discharged to nursing facility, but soon left AMA Could not be found for 5 days until he was located at a city homeless shelter Finally completed 6 months of treatment in 7 months (due to exceptional outreach efforts) Did not show for his 6 month post treatment follow up Objective 3 Review strategies to prevent tuberculosis in those with alcohol use disorder and latent tuberculosis infection. 11

12 Case 1: C.B. C.B. is a 44 y.o. man with a history of hepatitis referred from a homeless shelter for a +PPD Reports drinking 6 12 beers per day Exam has no TB findings, and CXR is normal Do you treat for LTBI? Yes, I would treat LTBI Case 1: C.B. Poll No, I would not treat LTBI To Treat or Not To Treat? Issues: Risk vs benefit Risk of Drug Induced Liver Injury (DILI) Benefit of preventing active TB Will he take the medication? How will you follow him? 12

13 TB Hepatotoxicity Guidelines Am J Respir Crit Care Med. 2006;174: TB Hepatotoxicity Guidelines: LTBI Pretreatment Evaluation ATS TB Hepatotoxicity Guidelines 13

14 LFTs are normal Case 1: C.B. Patient agrees to treatment says he will cut down the drinking What regimen should we use? LTBI Regimens: Poll Which LTBI Regimen would you choose? a) INH x 9 months b) INH x 6 months c) INH and Rifapentine x 12 weeks d) Rifampin x 4 months Case 1: CB Treatment Options Rifampin vs INH Rifapentine INH Rifapentine = 3HP 14

15 3HP PREVENT TB Trial 9H SAT vs 3HP DOT Enrolled 8053 patients N Engl J Med. 2011;365: HP PREVENT TB Trial 3817 (~50%) reported using alcohol 255 reported abusing alcohol 194 reported having cirrhosis 196 had Hepatitis C 102 had Hepatitis B N Engl J Med. 2011;365: HP PREVENT TB Trial 15

16 Monitoring for Hepatotoxicity during LTBI Treatment TB Hepatotoxicity Guidelines *anecdote Bhutanese Refugee Objective 4 Review alternative TB regimens when treating TB patients with alcohol use disorder 16

17 Case 2: L.T. 64 y.o. Man with HepC, AUD, referred for abnormal CXR. RUL cavity with 4+ AFB smear, probe+ MTB HepC +: untreated, viral load = 2 million Drinks a fifth a day fifth of a gallon or 25 fluid ounces (757 ml) AST = 180, ALT=90, Normal Bili Approach to Treatment TRANSFER? Approach to Treatment Not treating is not an option Best to construct a regimen with TB as well as hepatology expertise input 17

18 Less Hepatotoxic Regimens Treating without Pyrazinamide (PZA) INH/Rifampin/Ethambutol x 9 months Treating without INH and PZA Rifampin/Ethambutol/Fluoroquinolone Treating without INH/PZA/Rifampin Call TBEXPERT Monitoring for Hepatotoxicity during Active TB Treatment Conclusions Alcohol Use is common in the U.S. and among TB patients Alcohol use disorder presents challenges to TB treatment: increasing side effects and decreasing adherence Always seek help when unsure 18

19 Thank you! Questions? Continuing Education Units You ll be required to do a post test and an evaluation before printing your certificate Please give NTNC feedback on this webinar we want to plan more member only webinars and want to know your priorities. Thank you! It s been a pleasure to provide this education to you all. Many thanks to our speakers, our moderator, our NTNC membership committee, and the staff at BlueSky for their hard work and dedication. Now, complete the evaluation and post test and receive your certificate! If viewing as part of a group, your attendance code is NTNC