Introduction to TB Nurse Case Management Online February 4, 11, 18 and 25, 2015

Transcription

1 Introduction to TB Nurse Case Management Online February 4, 11, 18 and 25, 2015 TB Medications and Adverse Drug Events Presented by Evelyn Drzymala, RN, BSN February 11, 2015 Evelyn Drzymala, RN, BSN has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Objective Discuss the nursing interventions and medical management of the most common adverse drug events Case studies Overall Goals for Treatment of Tuberculosis Provide the safest and most effective therapy in the shortest period of time Minimize the risk of death and disability in patients Cure the individual patient Minimize the transmission of Mycobacterium tuberculosis to other persons 2

3 TB Disease and Treatment Key Nursing Responsibilities Have adequate skills and knowledge Have a caring attitude Develop rapport and trust beginning at the first patient visit. Key Responsibilities: Cultural Competency Assess attitude and beliefs Assess lifestyle and priorities If there is a language barrier Utilize interpreters for maximum efficacy of education, assessments, etc. Utilize the Language Line 3

4 Test your knowledge How might you as a TB nurse case manager be able to incorporate culturally competent care into your patient s plan of treatment? Key to Success: Effective Patient Education Begins with first interaction Assess literacy level Use understandable language (oral and written) Provide printed materials as available Include family if available Reinforce educational messages at every visit Give clear instructions regarding side effects/adverse drug reactions and when to report them to the health care provider. Document!! Allow opportunities for questions. 4

5 Additional Key to Successful Treatment Clinical monitoring Absolutely necessary to do Absolutely necessary to do well Absolutely necessary to document well What Are We Monitoring For? Side effects of the medications Adverse drug events Compliance with treatment 5

6 Side Effects Unpleasant, but mild reactions No long lasting health effects Do not usually require changes in therapy Gas Bloating Mild nausea Discoloration of body fluids Irritability Difficulty sleeping Photosensitivity Adverse Drug Reactions TB Drug Toxicities More serious May be life threatening Require modifying the dose/discontinuation of drug May require additional therapy and/or hospitalization Significant GI disturbances Hepatoxicity Dermatologic and hypersensitivity reactions Ophthalmic toxicity CNS toxicity Neurotoxicity Ototoxicity Musculoskeletal adverse effects Renal toxicity 6

7 Drug Monitoring Goals Recognize adverse drug events Assess appropriately Intervene rapidly Prevent further morbidity/mortality Minimize treatment interruptions Avoid development of psychological intolerance Support adherence and the therapeutic relationship Reference: Core Curriculum on Tuberculosis. What the Clinician should know. Page

8 Standard of Care for initiating treatment of TB disease Four drug therapy TB can usually be cured with a combination of first-line drugs taken for several months. Standard combination first line drugs include: Rifampin Isoniazid Pyrazinamide Ethambutol Test Your Knowledge What are the standard first line drugs for treatment of TB disease? 8

9 Gastrointestinal Most difficult side effects at initiation of TB treatment Nausea and vomiting Abdominal cramps and increased flatulence Managing Side Effects Administer antiemetics prior to medications or as needed Try to separate the responsible medication from other drugs by several hours or give it before bedtime to allow most of the adverse effects to occur during sleeping. Pregnancy should be considered as possible etiology of nausea and vomiting, especially if the symptoms occur after a period of initial tolerance. Dermatologic and Hypersensitivity Reactions Maculopapular Rash and Pruritis Common early side effects Minor dermatologic reactions Benadryl Atarax Topical hydrocortisone cream prior to the antituberculosis drug or as needed. 9

10 Evaluate Other Potential Etiologies of Rash and Pruritis Scabies and insect bites may masquerade as a drug rash Contact dermatitis (question patient about use of new lotions, soaps, perfumes, etc) Phototoxicity (may cause dermatitis, may respond to sunscreens) Dry skin, especially in diabetic patients may be the cause. Consider liberal use of lotions and creams Flushing Reactions Flushing and itching of the skin without a rash involving the face and scalp Redness and watering of the eyes Usually due to Rifampin or Pyrazinamide Usually mild and self-resolving If bothersome, antihistamine may be administered to treat or to prevent the reaction 10

11 Dermatologic Toxicity Drugs should not be continued if there are systemic symptoms: Fever, Urticaria Mucous membrane involvement Blistering of skin Edema of lips/eyes Wheezing/compromise of airway Neurotoxicity Peripheral Neuropathy Tingling, prickling, and burning in the balls of the feet and tips of the toes. May involve the fingers and hands Unsteadiness of gait may develop due to proprioceptive loss More likely to occur in patients with diabetes, alcoholism, HIV infection, poor nutrition, and with inadequate dietary intake of pyridoxine 11

12 Drugs Most Commonly Implicated INH Ethionamide Cycloserine Linezolid Interventions Pyridoxine prophylaxis Usually given anywhere from 25 mg to 100 mg PO daily Correct nutritional deficiencies Supportive medication therapies often prescribed Gabapentin Lamotrigine Trileptal Tramadol As the DOT nurse, become familiar with your patient s medications; their actions and side effects so that effective monitoring can occur 12

13 Central Nervous System Toxicity Early in therapy drowsiness, headaches, irritability, mood changes, insomnia, agitation. Educate patients to expect these and understand they typically become lessened Tolerance develops towards most of these effects Patient learns to cope with them. Central Nervous System Toxicity Depression Situational depression expected Assess and address underlying psycho/social issues Assess for coexisting substance abuse and refer to counseling if appropriate When depression more significant antidepressant therapy may be instituted Refer to psychologist Psychiatry referral 13

14 Hematologic Abnormalities Leukopenia Thrombocytopenia Anemia Coagulation abnormalities Eosinophilia **Regular lab monitoring essential Opthalmic Toxicity Ethambutol Most common drug causing toxicity to the optic nerve Ethionamide, Linezolid, Rifabutin, INH, and Clofazamine are rare causes 14

15 When Using Any of These Drugs Conduct baseline visual assessment at initiation acuity testing (Snellen chart) testing of color discrimination (Ishihara test) Conduct monthly testing of visual acuity and color discrimination during treatment Educate patients to report any change in visual acuity or red-green color discrimination, changes in visual fields, erythema, or eye pain. In diabetics, assess diabetic control Retrobulbar Neuritis Retrobulbar neuritis is a form of optic neuritis in which the optic nerve, which is at the back of the eye, becomes inflamed. When these fibers become inflamed, visual signaling to the brain becomes disrupted, and vision is impaired. 15

16 Retrobulbar Neuritis EMB is stopped Patient referred to opthalmologist EMB not restarted unless another cause of the neuritis or vision problem definitely identified Rare cases of optic neuritis have been linked to Linezolid, Ethionamide, and Clofazimine Gradual improvement in vision is noted in many patients after the offending medication is stopped Uveitis Uveitis is swelling and irritation of the uvea, the middle layer of the eye. The uvea provides most of the blood supply to the retina. Uveitis is the third leading cause of blindness in the United States. 16

17 Uveitis Rifabutin, especially in higher doses can cause eye pain and uveitis. Notify the doctor right away if eye pain or blurring of vision occur in a patient taking Rifabutin. Typically, Rifabutin put on HOLD until symptoms resolved. Consider restarting at a lower dose If uveitis recurrent, Rifabutin stopped. Opthalmology consulted. Musculoskeletal Adverse Effects Myalgias and Arthalgias Common side effects associated with a variety of drugs used to treat TB PZA, Rifabutin, INH, Ethionamide NSAIDs are usually helpful 17

18 Hepatotoxicity Any GI complaint could represent liver toxicity Liver toxicity could be due to 3 of the 4 first line TB meds INH, Rifampin, PZA Bilirubin and alkaline phosphatase increases Typically with Rifampin Hepatotoxicity Patient Symptoms Fatigue Abdominal pain Fever for 3 or more days Nausea/vomiting Flu-like symptoms Lack of appetite Dark urine Yellowing of skin/eyes 18

19 Hepatotoxicity If s/s of liver toxicity Hold all TB meds until lab results known If normal LFTs may continue TB meds ALT (SGPT) more specific for liver injury AST (SGOT) indicate abnormalities of muscle, heart, or kidney ALT > AST consistent with liver inflammation AST > ALT consider alcohol related elevation Regular monitoring of LFT s important Ototoxicity No first line drugs have this adverse effect Streptomycin 2 nd line drug Aminoglycosides Amikacin and Capreomycin Cause vestibular and auditory toxicity Regular audiometry and vestibular testing a must! 19

20 Case Study #1 32 year old female with Renal TB. Started on daily RIPE therapy. OP-DOT. Non-compliant with OP-DOT. Reported feeling depressed. Also c/o itching, mood swings, night sweats, and fevers that all went away after stopping medications. Court-ordered hospitalization resulted. On 2 nd hospital day, TB meds reintroduced one med at a time. Started with Rifampin and pre-treatment with Atarax and Zofran. Tolerated well except for some stomach discomfort. Next day, Prednisone 40 mg PO daily added to prevent inflammation of ureter since she had Renal TB; Protonix also added to buffer stomach discomfort. Hospital day 4 Started INH and Pyridoxine 100 mg PO. Well tolerated. Days 5,6,7, and 8 tolerating above regimen well. Case Study #1 Day 9 PZA 1500 mg PO daily added. Within 15 minutes of PZA dose, patient complaining of intense itching all over her body. Extremly anxious. No hives or SOB noted. MD notified. Benadryl 50 mg PO given STAT with resolution of symptoms. 20

21 Case Study #1 Subsequently, Continued on Rifampin, INH, and PZA with Benadryl 50 mg PO one hour prior to TB meds. Prednisone, Zofran, and Protonix pre-treatment also continued. Patient continued to tolerate regimen well until Benadryl pretreatment discontinued. Developed itching and anxiety again. Atarax 25 mg PO daily added to regimen to prevent the drowsiness that generally accompanies Benadryl. Prednisone tapered off. Patient successfully continued on Rifampin, INH, PZA, Zofran, Protonix, and Atarax as her regimen. Case Study #1 Challenges Young female with pre existing anxiety Anger and situational depression over being court ordered to an in patient facility Separation from her young children Being subjected to a drug re challenge that she believed previously made her physically ill 21

22 Case Study #1 Challenges continued The Challenge was to provide her lots of empathic nursing care while supporting her back into an effective TB regimen. Case Study #2 54 year old homeless female admitted to TCID with PTB after a 6-month period of cough, fever, chills, night sweats, and n/v. 45 lb. weight loss during this 6-mo period. Admission weight 115. Height 64 Patient had 2 hospitalizations during this timeframe. Treated for Pneumonia. Symptoms persisted. PTB was confirmed by + NAAT culture. Susceptibilities still pending on admission to TCID. 22

23 Case Study #2 - continued On admission to TCID Rifampin, Vitamin B6, PZA, INH, Myambutol Metformin for underlying Diabetes; Lisinopril for underlying HTN After initiation of treatment Severe nausea and vomiting Zofran BID and PRN added A month into hospitalization n/v, appetite improved Follow-up sputum studies INH resistant INH stopped. Moxifloxacin added to regimen Extreme n/v returned. Zofran 8 mg PO added every morning 30 mins. prior to TB meds. Case Study #2 - continued One week later Extreme n/v persist following AM administration of Rifampin and Moxifloxacin. Denies n/v later in the day. Weight down to 109 lbs. PO Rifampin and Moxifloxacin discontinued Switched to IV. PICC line placed. PZA and EMB continued PO. Glucerna nutritional supplement added BID for nutritional support. 23

24 Case Study #2 - continued The following day No nausea or vomiting A happy patient 2 days later n/v x 2 episodes at 0700 and 1100 (after AM meds) No changes made let s see what happens Case Study #2 - continued For the next two weeks Tolerating all meds without any n/v Appetite improved Slight weight gain Switched back to PO meds Rifampin, Levofloxacin, in addition to the PZA and EMB Tolerated regimen well this time PICC line removed Nutrition improved Weight continued to improve 24

25 Case Study #2 Challenges very thin emaciated female on admission persisting significant GI toxicity patient losing weight instead of gaining sputums taking longer to convert to negative longer than average period of time in AFB isolation situational depression Case Study #2 challenges continued How were these challenges managed? Lots of supportive medical and nursing care. With frequent adjustments to the TB regimen, the pretreatments, and the PRN treatments. With our very strong nutritional support system at TCID. Patient allowed diet of choice and it was provided until the nausea and vomiting subsided. Then at that point, she was transitioned to a Diabetic diet. 25

26 Case Studies Teaching Points Every patient has a unique story. Unravel that story using your therapeutic nursepatient relationship Put yourself in your patient s shoes if at all possible. Always treat your patients like you would like to be treated yourself. References Drug Resistant TB: A Survival Guide for Clinicians; 2 nd edition; Curry International TB Center CDC Core Curriculum on TB: What the Clinician Should Know; 5 th edition Clinical monitoring and follow-up for Tuberculosis Treatment; Section VI 26

27 References Kwok, Dr. Alvin. Ocular Toxicity of Ethambutol. Vol. II, No. 2 February Ramadan starts in United States Uveitis Nucleic Acid Test References Retrobulbar Neuritis Guide guide/ retrobulbar neuritis.html 27

28 Thank You 28