Evaluation and Treatment of TB Contacts Tyler, Texas April 11, 2014 Monitoring Patients for TB Adverse Reactions and Managing Side Effects Catalina Navarro, RN, BSN April 11, 2014 Catalina Navarro, 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
Monitoring Patients for TB Meds Adverse Reactions and Managing Side Effects Catalina Navarro RN BSN TB Nurse Consultant/Educator Objectives Describe the monitoring process for adverse drug events Discuss side effects and drug toxicities Recognize the most common adverse drug events Discuss the nursing interventions and medical management of the most common adverse drug events 2
Goals of TB Treatment Cure the patient Minimize the risk of death & disability Reduce transmission NOTE: Responsibility of successful treatment is assigned to the health care provider NOT THE PATIENT Purpose of Monitoring Patient Recognize adverse drug events Assess appropriately Intervene rapidly Prevent further morbidity/mortality Minimize treatment interruptions Reduce opportunities for medical mismanagement Avoid development of psychological intolerance Support adherence and the therapeutic relationship 3
Side Effects Occur in addition to the desired therapeutic effect Unpleasant, but mild reactions No long lasting health effects Do not usually require changes in therapy Adverse Drug Reaction More serious May be life threatening Require modifying the dose/discontinuation of drug May require additional therapy and/or hospitalization 4
Side Effects Adverse Drug Reaction Gas Bloating Mild nausea Discoloration of body fluids Irritability Difficulty sleeping Photosensitivity Significant GI disturbances Dermatologic/ hypersensitivity reactions Ophthalmic toxicity CNS toxicity Neurotoxicity Ototoxicity Musculoskeletal Renal toxicity All Medications Have Side Effects Most TB patients complete their treatment without any significant adverse drug effects Risk/Benefit ratio of medication used Explain beneficial effects of medications and possible side effects/adverse events The benefits provided by the medicine worth the risk 5
? Possible side effects of acetaminophen Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop taking this medication and call your doctor at once if you have a serious side effect such as: low fever with nausea, stomach pain, and loss of appetite; dark urine, clay-colored stools; or jaundice (yellowing of the skin or eyes). This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA. Benefits Vs. Risks 6
Don t Forget: Explain to patient that there will be side effects to the medications - but you will work with them to manage them Patient education & charting of education First-line Drugs Isoniazid (INH) Rifampin (RIF) Rifabutin Ethambutol (EMB) Pyrazinamide (PZA) 7
Side Effects of First Line Drugs INH G.I. upset Peripheral neuropathy PZA G.I. upset Arthralgias Gout (rare Rifampin G.I. upset Thrombocytopenia, hemolytic anemia Renal toxicity Flu-like syndrome Orange staining of body fluids Optic Neuritis Ethambutol Rifabutin /Skin discoloration Leukopenia Thrombocytopenia Uveitis Arthralgias 8
Peripheral Neuropathy Tingling, prickling & burning balls of feet or tips of toes More likely: Diabetic, alcoholic, HIV infection, pregnancy, poor nutrition, hypothyroidism Sensory loss can occur; ankle reflexes lost; unsteady painful gait Can progress to the fingers and hands Administer Vitamin B6 (pyridoxine) 50mg daily Note: B6 in doses greater than 200mg can CAUSE neuropathy Musculoskeletal Adverse Effects Aches & Pains Variety of TB meds can cause INH, PZA, Rifabutin, fluroquinolones Do Not Stop meds NSAIDS can be helpful 9
Gastrointestinal (GI) Upset Gastro Intestinal Upset INH G.I. upset Peripheral neuropathy Mild CNS Toxicity Rifampin G.I. upset Thrombocytopenia, hemolytic anemia Renal toxicity Flu-like syndrome Orange staining of body fluids Rifabutin /Skin discoloration Leukopenia Thrombocytopenia Uveitis Arthralgias PZA G.I. upset Arthralgias Gout (rare Ethambutol Optic Neuritis 10
Gastrointestinal Upset Nausea/vomiting/diarrhea (NVD) Common in the first few weeks of therapy Give a light snack before meds Gastrointestinal (GI) Upset Administer antiemetic Phenergan Zofran Plasil Administer antacids but NOT given within 2 hours of fluoroquinolones Encourage hydration ( Sports drinks electrolyte replacement) 11
Monitoring Gastrointestinal (GI) Upset Evaluate the interventions Nausea decreased? Persistent throughout the day? May need to stop the offending medication Is there an adequate replacement? If no, patient may need to tolerate some n/v. If yes, consider switching medication May need expert consultation before switching meds Hepatotoxicity 12
Hepatotoxicity with First Line Drugs INH G.I. upset Peripheral neuropathy Mild CNS Toxicity PZA G.I. upset Arthralgias Gout (rare Rifampin G.I. upset Thrombocytopenia, hemolytic anemia Renal toxicity Flu-like syndrome Orange staining of body fluids Ethambutol Optic Neuritis Rifabutin /Skin discoloration Leukopenia Thrombocytopenia Uveitis Arthralgias Hepatotoxicity Early Signs Fatigue Poor appetite Taste alteration Nausea Abdominal discomfort Bloating Minimal rash Later Signs Vomiting Abdominal pain Jaundice Change in color of urine and stool Changes in behavior, memory loss 13
Risk Factors for Hepatotoxicity Underlying liver disease Hepatitis B and C Alcoholism Immediate (4 months) post-partum period Hepatotoxic medications Hepatotoxic Drugs Tylenol Tetracycline, erythromycin, others Dilantin Valproate Cholesterol lowering medications Antifungal drugs Glucose lowering drugs Valium 14
Monitoring Medical history Preexisting conditions may increase hepatotoxicity History of Hepatitis B or C History of other liver disease Social history ETOH use (be specific) Educate patient of signs and symptoms of hepatotoxicity Managing Hepatotoxicity Check Liver Function Test (LFT) at baseline and monthly Stop therapy LFT s> 3 times upper limit of normal and symptomatic LFTs> 5 times upper limit of normal and asymptomatic 15
Re-Challenge Restarting therapy LFT s must be < 2 times upper limit of normal Rechallenge Medications Introduce one drug at a time Monitor enzymes carefully Stop therapy if symptomatic or increased enzymes Eliminate last drug added from regimen 16
Case Study #1 65 y/o female diagnosed with PTB on December 2013 Chest X-ray abnormal AFB smear (+) NAAT (+) Culture pending Baseline labs WNL RIPE started on December 16 th Re-Challenge? December January February 16 23 30 6 13 20 27 3 10 17 24 INH RIF PZA EMB LFT s WNL 2xUNL >3xUNL 2xUNL WNL WNL 5xUNL 17
Case Study #2 35 y/o male diagnosed with PTB on February 2014 Chest X-ray abnormal AFB smear (+) NAAT (+) Culture pending Baseline labs WNL RIPE started on March 10 th LFT s WNL 18
Re-Challenge TB Meds (Hepatotoxicity) FEBRUARY MARCH APRIL 3 10 17 24 3 10 17 24 31 7 14 INH RIF PZA EMB WNL >3x UNL>2x UNL WNL Rechallenge TB Meds (Hepatotoxicity) APRIL MAY JUNE JULY 14 21 28 5 12 19 26 2 9 16 23 30 RIF INH PZA EMB LFT s WNL WNL WNL >3xUNL 2xUNL WNL 19
Rechallenge TB Meds (Hepatotoxicity) APRIL MAY JUNE JULY 14 21 28 5 12 19 26 2 9 16 23 30 RIF INH 9 months of Rx. PZA EMB Pansuscep. LFT s WNL WNL WNL WNL Rash 20
Rash INH G.I. upset Peripheral neuropathy Mild CNS Toxicity PZA G.I. upset Arthralgias Gout (rare Rifampin G.I. upset Thrombocytopenia, hemolytic anemia Renal toxicity Flu-like syndrome Orange staining of body fluids Ethambutol Optic Neuritis Rifabutin /Skin discoloration Leukopenia Thrombocytopenia Uveitis Arthralgias Evaluate the Rash Where is it? What does it look like? Does it itch? When did it start? Has it spread? What makes it better or worse? Have you had an insect bite? 21
Other Possible Causes Insect bites Scabies Contact dermatitis Question patient about new soaps, lotions, perfumes, laundry detergents, etc Sunburn Dry skin Other drugs, especially new agents Viral or fungal infections Common Mild Rash Often resolve after first several weeks of treatment Usually do not require stopping medication Treated symptomatically with Benadryl, other antihistamines, low-dose prednisone 22
Rash: Hypersensitive Reaction Petechial Rash Thrombocytopenia with Rifampin Do platelet count What was the baseline? If low suspect hypersensitive reaction to Rifampin Consult with clinician STOP Rifampin monitor platelets until normal Rifampin should not be restarted Additional medication will need to be added Will increase treatment length w/o Rifampin May need expert medical consultation Rash: Hypersensitive Reaction Generalized erythematous rash: Assoc with fever OR mucous membrane involvement STOPTB medications call clinician If Anaphylaxis call 911 Drug re-challenge If no anaphylaxis or airway compromise May consider drug re-challenge See Drug Resistant TB Curry National TB Center p.153 http://www.currytbcenter.ucsf.edu/drtb/drtb_ch7.cfm 23
Rifabutin Decreased WBC Decreased Platelet count Renal Impairment Hyperpigmentation Flushing G.I. upset Uveitis Painful pink eye Arthralgias Joint pain Uveitis When given in higher doses with drugs that decrease renal clearance Hold rifabutin until symptoms resolve Consider referral to ophthalmologist to rule-out other cause If infection is ruled-out, steroid eye drops may be used If recurring uveitis, stop rifabutin 24
Ethambutol Nausea Vomiting Loss of appetite Fever Headaches Dizziness Changes in visual acuity Changes in red/green color discrimination Managing & Monitoring Visual Toxicities Baseline & monthly visual acuity test (Snellen chart) Baseline & monthly color discrimination test (Ishihara tests) Question about visual disturbances including blurred vision Children to look for eye rubbing, excessive blinking, sitting close TV, difficulty with accurate grasping Hold EMB Refer for Ophthalmologic evaluation Permanent vision impairment if Rx continued 25
Snellen Eye Charts You will need: Ishihara Test Ishihara s Tests for Colour Deficiency 24 Plate Edition Well lit room(natural day light is preferred) Comfortable chair for patient Quiet room 26
Ishihara Plate Examples Case Study INH Resistant TB 21 year old male diagnosed with PTB CXR showed LUL cavitary infiltrate, AFB smear Cx (+) On October 2012: RIPE started Isolate reported Resistant to INH and Streptomycin INH discontinued once susceptibilities were known, Pt. continued on RIF, PZA, EMB to complete 9 months of adequate therapy 27
Case Study EMB Side Effects What Toxicities is a patient on EMB at risk for? Optic Neuritis Decreased visual acuity Decreased red-green color discrimination Case Study Vision Monitoring What baseline testing should you do for your patient who is starting EMB? Visual Acuity (Snellen) Ishihara 28
Case Study - Ophthalmic Toxicity 5 months after treatment initiation patient c/o difficulty driving and reading road signs As a nurse managing this patient s anti-tb therapy, what would you do? To assess vision screen Stop the EMB Refer to the Ophthalmologist Case Study Follow Up Patient contacted nurse by phone, she instructed him to see his eye doctor. He was seen by optometrist and given corrective lenses. EMB was continued 29
Case Study Visual Monitoring Results 7 months on anti-tb therapy he complains of worsening vision. Nurse finally assess his vision Baseline visual acuity in October: 20/20 both eyes Follow up visual acuity: 20/200 in both eyes. EMB was discontinued Pt. continued on RIF, PZA Levofloxacin was added to complete 9 mo of treatment Referral to a retinal specialist. Case Study Conclusion During the last two months of treatment pt evaluated by retinal specialist DX: EMB optic neuropathy Central scotoma on right and parascotoma on left Vision uncorrected: 20/200 Nurse admitted to not performing visual acuity screening (Snellen chart), she only did color discrimination testing (Ishihara plates) 30
Musculoskeletical Adverse Effects Arthralgia with First Line Drugs INH G.I. upset Peripheral neuropathy Mild CNS Toxicity PZA G.I. upset Arthralgias Gout (rare) Rifampin G.I. upset Thrombocytopenia, hemolytic anemia Renal toxicity Flu-like syndrome Orange staining of body fluids Ethambutol Optic Neuritis Rifabutin /Skin discoloration Leukopenia Thrombocytopenia Uveitis Arthralgias 31
Arthralgia With Second Line Drugs Amikacin Rash Renal toxicity Ototoxicity Vestibular toxicity Electrolyte abnormalities (hypokalemia, hypomagnesemia) Local Pain at the injection site Levofloxacin, Moxifloxacin GI upset (rare) Mild CNS toxicity Arthralgias, rare tendon rupture Photosensitivity EKG abnormalities Capreomycin Renal Toxicity Ototoxicity Vestibular Toxicity Electrolyte abnormalities (hypokalemia, hypocalcemia, hypomagnesemia) Local pain at the injection site Ethionamide GI upset, may be significant Endocrine effects (gynecomastia, hair loss, acne, impotence, menstrual irregularity, reversible hypothyroidism) Peripheral neuropathy Musculoskeletal Adverse Effects Aches, Pains, Myalgias, Arthralgias Usually not necessary to D/C meds NSAIDS can be helpful If acute swelling, erythema, warmth present, evaluate for infection, gout PZA rarely increase in uric acid gout except in patients with pre-existing gout or decreased renal function 32
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Sources: CDC Core Curriculum on TB: What the Clinician Should Know; 5 th edition http://www.cdc.gov/tb/education/corecurr/index.htm TB Nursing: A Comprehensive Guide to Patient Care; 2 nd Edition http://www.tbcontrollers.org/resources/tb-nursingmanual/#.uavinjxnerg Drug- Resistant TB: A Survival Guide for Clinicians; 2 nd Edition; Curry International TB Center http://www.currytbcenter.ucsf.edu/drtb/ TB Drug Information Guide 2 nd Edition; Curry International TB Center http://www.currytbcenter.ucsf.edu/products/product _details.cfm?productid=wpt-17a 34
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