Treatment and Monitoring

Treatment and Monitoring

Disclosures We have no actual or potential conflicts of interest in relation to this presentations. We have no financial relationships to disclose.

Learning Objectives After this session, participants will be able to: Discuss the team members involved in managing care Describe the TB treatment regimens

Case Management Process Interview Phase Case Interview Assessment Address Barriers to Adherence Contact Investigation Plan Treatment and Monitoring Completion of Treatment

Managing TB care Collaboration with the private provider, if there is one, is critical If a private provider is involved negotiate Monthly assessments Sputum collection Radiography Vision and auditory exams laboratory monitoring Other assessments needed DOT will most often be done by the Health Department A contact investigation is the responsibility of the health department. This is Pure public health

Amelia Her story continues She lives with her boyfriend and her 3 children ages 2, 6 and 7. Her sister, brother-in-law and their 2 young children also live in the home. She works at night and her boyfriend works during the day. She has not been at work for over over one month and her boyfriend has stayed home to watch the children. She was told she had diabetes 3 years ago. Amelia has no insurance. The hospitalist explained that upon discharge the health department needs to monitor from then on.

Team Members Who is involved in every TB case in your area? Who would be part of the team caring for Amelia day to day? Do roles overlap?

Treatment of Drug Susceptible TB Guidelines 2016 Utilize case management interventions during treatment of cases with tuberculosis

Key Treatment Regimen Highlights DOT is the standard of care. Daily (5 or 7) rather than intermittent dosing during the initial (intensive) phase is recommended. Daily or three times weekly (TIW) dosing in the continuation phase is recommended. Alternative regimens that are variations of the preferred regimen may be acceptable in certain clinical and public health siturations. Once weekly regimens(inh/rpt) in the continuation phase should not be used. 4 month regimens are adequate for HIV (-), culture (-) adults.

Key Treatment Highlights - HIV Positive TB Cases Preference is to not use an intermittent regimen. 6 months of daily treatment can be used if the case is taking Antiretroviral s (ARV) during TB therapy. Those who are not on ARV should receive no less than 9 months of TB therapy. For those who are not on ARV s when diagnosed with TB ARV therapy should be initiated within the first two weeks in those with CD4 counts less than 50/mm and within 8-12 weeks in those with CD4 counts greater than 50/mm Those who are diagnosed with TB Meningitis SHOULD NOT start ARV prior to completing 8-10 weeks of TB therapy regardless of their CD4 count.

TB Drugs Rifampin Isoniazid Pyrazinamide Ethambutol RIPE Essential for short-course TB regimens Turns body fluids orange Flu like symptoms Cousin to rifabutin, & rifapentine Used only for TB Headache, nausea, fatigue neuropathy Tyramine food reaction Bactericidal Used only for TB Works best early in treatment Achy joints (arthralgia) Bactericidal & Bacteriostatic Safety net drug Color vision Vision acuity Stomach issues Bacteriostatic Bactericidal ALL: rash, nausea, fatigue, abdominal pain, drug fever

TB Treatment Regimens Insert graphic of new chart Page 4

The Two Phases of a Standard TB Treatment Regimen No longer recommended Time in months Initial Phase Continuation Phase

4 drugs Initial Phase Exceptions - pregnancy/ no PZA Exceptions - young children / some may exclude EMB 2 regimens, 1 & 2 are daily dosing Regimen 3 is TIW for 24 doses Regimen 4 begins with daily, ends with BIW

Time for math!

Calculating Dosages All medication dosages are calculated based on milligram/kilogram. Therefore to determine if RIPE dosing is correct you must convert pounds (lbs.) to kilograms (kg.) 160 lbs. 2.2 = 72.7 kg.

Treatment Quirks Daily does not simply mean 7 days/week. It means 5 days/week most of the time. Treatment weeks calendar weeks. Calculate treatment weeks Total doses taken Frequency of administration = Total treatment weeks.to determine if treatment is complete.

More Treatment Quirks 6 months of treatment 24 weeks, it equals 26 weeks because 52/2=26 Months Weeks Initial phase Continuation phase 6 = 26 8 + 18 9 = 39 8 + 31 4 = 16 8 + 8 12 = 52 No true initial phase/ continuation phase Surprise! Surprise! Many patients do not complete treatment exactly by the book.

PZA and EMB - Whole Tablet Dosing Page 26

PZA and EMB - Whole Tablet Dosing wgt. 150# (68.2kg) = PZA 3, EMB 3 Page 26

PZA and EMB - Whole Tablet Dosing There will likely be the same # of tablets for both wgt. 150# (68.2kg) = PZA 3, EMB 3 Page 26

Treating Amelia What s emphasized

Amelia weighs 126 lbs Calculate her weight in kilograms Adult dosing Rifampin 10mg/kg Isoniazid 5mg/kg Pyrazinamide chart page 26 Ethambutol chart pg 26

Reactions requiring immediate report Hold medication Jaundice Dark urine Vomiting Abdominal pain Fever Visual changes Marked rash

Reactions requiring a report in 24 hrs Do not hold without an order Anorexia Nausea Malaise Peripheral neuropathy Rashes

Addressing Treatment Complaints Common, manageable side effects Fatigue Nausea Rash without hives Headache Tyramine reaction Peripheral neuritis Arthralgias Sunburn

Common Problems/Simple Solutions (1) Fatigue take meds at the end of the day Reassure should improve with time GI symptoms/dyspepsia Light meal Stomach acid reducers

Common Problems/Simple Solutions (2) Rash Questions to Ask Has this happened in the past? When does it happen? Localized or generalized? Itchy? Painful? Hot? Dry? Do not presume it is an allergic reaction Topical treatment: corticosteroids, topical anesthetics or antihistamines Oral antihistamines Moisturizing may help

Common Problems/Simple Solutions (3) Headache Take medication later in the day Improve nutritional intake Tyramine reaction Self limiting: headache, palpitations, upper body flushing and itching, Consider food preferences Not an allergic reaction but consider antihistamines

Common Problems/Simple Solutions (4) Peripheral Neuritis Diabetic? Vitamin B6/pyridoxine: 25, 50, 75, 100 and beyond Arthralgias Other co-morbidity Likely Rifamycin? (generalized) Likely PZA? (joints) Menopause? Mild analgesic

Common Problems/Simple Solutions (5) Sunburn Stay out of sun, HOWEVER, may not be as easy Wear protective cotton clothing Use sun block!

Amelia s Story She lives with her boyfriend and her 3 children ages 2, 6 and 7. Her sister, brother-in-law and their 2 young children also live in the home She works at night and her boyfriend works during the day. She has not been at work for over over one month and her boyfriend has stayed home to watch the children. She was told she had diabetes 3 years ago. Amelia has no insurance. The hospitalist explained that upon discharge the health department needs to monitor from then on.

Factors that could Impact Treatment Obvious Currently unemployed Infectious young children in home Diabetic access to care? Uninsured comorbidity management? Evaluation of young children Potential Fear/isolation/guilt Treatment may be effected by diabetes

Going back to work Life happens! DOT Flexibility Location, Time, Frequency Moving Working with other jurisdictions Reporting district maintains case management responsibility Working district communicates status Provide labs, DOT records Family/Friend difficulty Living arrangements Broken relationships