Dose Counting Exercise Elizabeth Foy, RN, BSN September 8, 2016 TB Nurse Case Management September 7-9, 2016 San Antonio, TX EXCELLENCE EXPERTISE INNOVATION Jessica Quintero, M.Ed., has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
Standard Dosing concepts Treatment should be completed 365 days from initiation of therapy (if applicable) Count dosesand weeksnot just months of therapy Months are counted in weeks and days, not all months are 4 weeks 5 days/week is shown to be as effective as 7 days/week of directly observed therapy, either is provider-dependent Any interruption of treatment in initial phase longer than 14 days means treatment should be restarted 2
Standard Dose Counting Typical duration for pulmonary tuberculosis is: Or 2 month initial phase + 4 month equivalent continuation phase = 6 months of therapy 2 month initial phase + 7 month equivalent continuation phase =9 months of therapy Initial Phase Initial phase always 8 weeks, and the doses are: 40 doses (8 weeks if given 5 days/week) Or 56 doses (8 weeks if given 7 days/week) Or Intermittently (see chart; still 8 weeks) 3
Continuation Phase Continuation phase is always either approx. 4 months or 7 months (between 26-39 weeks) with varying doses Consider: about 4 month or 7 month phase depending on initial status of patient, but note weeks and doses are what s counted Dose Counting: 6 months Calculating : 6 months of treatment= 26 weeks of therapy (8 weeks initial phase + 18 weeks in continuation phase) Daily dosing: 7 days a week x number of weeks of treatment (for example 7 x 26 weeks) Daily dosing: 5 days a week x number of weeks of treatment (for example 5 x 26 weeks) Bi-weekly dosing: 2 doses x number of weeks of treatment (2 x 18 weeks of continuation phase) Tri-weekly dosing: 3 doses x number of weeks (3 x 18 weeks of continuation phase) 4
Dose Counting: 9 months Calculating : 9 months of treatment= 39 weeks of therapy (8 weeks initial phase and 31 weeks in continuation phase) Still calculate days x weeks, as done in previous slide Dose Counting TB Regimen 5
TB Regimen Dose Counting 32 y/o, 128 lb., Hispanic female with- AFB smears and +AFB cultures. CXR indicates minimal Upper lobe infiltrate. The physician has written the following orders: Give the following daily for 10 days INH 300 mg Rifampin 600 mg EMB 1200 mg PZA 1500 mg Vitamin B6-50 mg TB Regimen Dose Counting Followed by 12 doses bi-weekly: INH 900 mg Rifampin 600 mg PZA 3000 mg EMB 2800 mg Vitamin B6-100 mg Followed by 36 doses bi-weekly: INH 900 mg Rifampin 600 mg Vitamin B6-100 mg Is this an appropriate regimen? 6
How many weeks of therapy will the patient complete? A. 26 weeks B. 28 weeks C. 30 weeks D. 32 weeks 25% 25% 25% 25% 26 weeks 28 weeks 30 weeks 32 weeks TB Regimen Dose Counting How many weeks of therapy will the patient complete? Answer: 26 weeks 7
How many months does the number of weeks translate to? A. 4 months B. 5 months C. 6 months D. 9 months 25% 25% 25% 25% 4 months 5 months 6 months 9 months TB Regimen Dose Counting How many months does the number of weeks translate to? Answer: 6 months 8
Dose counting Exercise LTBI Dose Counting Standard Length of Treatment Drug Duration Frequency Doses Needed INH 9 months Daily 270 BIW 76 INH 6 months Daily 180 BIW 52 INH/RPT 3 months Once Weekly 12 RIF 4 months Daily 120 9
LTBI Dose Counting 20 y/o, 185 lb., Hispanic male. He is a contact to a patient with smear positive, culture confirmed M.TB. He was screened and evaluated. Results are as follows: IGRA positive No signs and symptoms of TB disease CXR reported as normal How many doses of LTBI treatment does patient need to complete LTBI treatment with INH BIW? A. 60-62 doses B. 76-78 doses C. 54 doses D. 36 doses 25% 25% 25% 25% 60-62 doses 76-78 doses 54 doses 36 doses 10
LTBI Dose Counting How many doses of LTBI therapy does the patient need to complete LTBI treatment with INH BIW? A. 60-62 doses B. 76-78 doses C. 54 doses D. 36 doses Answer: B.) Twice-weekly INH regimens should consist of at least 76 doses administered within 12 months for the 9- month regimen. Dose Counting Exercise Interruption 11
Interruption Dose Counting Interruption 82 y/o woman with history of stage IV ovarian cancer and diabetes. She began therapy with the standard 4 drug anti-tb therapy (RIPE) daily regimen on 6/01/2013. Shortly after initiation of therapy she started complaining of right upper quadrant pain and appeared to be jaundiced. Liver function tests were elevated more than 5 times the upper limits of normal. All medications were held 6/10/2013, and were not re-started until 6/28/2013. How long of an interruption was there? A. 12 days B. 14 days C. 16 days D. 18 days 25% 25% 25% 25% 12 days 14 days 16 days 18 days 12
Interruption Dose Counting How long of an interruption was there? Answer: 18 days; meds were held 6/10/2013-6/28/2013 Does the patient have to re-start anti-tb therapy? A. Yes B. No 50% 50% Yes No 13
Interruption Dose Counting Does the patient have to re-start anti-tb therapy? Answer: yes. If interruption occurs during the initial phase of treatment and the lapse is 14 days or more in duration, treatment should be restarted from the beginning. However, if the lapse is less than 14 days, the treatment regimen should be continued. Dose Counting Final thoughts Tools 14
Special Thanks to Barbarah Martinez from City of Houston Health and Human Services Department Thank you! 15