neha shah, md mph field medical officer · neha shah, md mph field medical officer california...
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Image from: fda.gov
Neha Shah, MD MPH
Field Medical Officer
California Department of Public Health
CITC video series: Basics of MDR-TB Clinical Care
Your patient WILL have at least one side effect
Common Side Effects
Side Effect Medication
Gastrointestinal complaints Ethionamide, PAS
Quinolones, Clofazmine, Rifabutin, Linezolid
Hearing loss, vestibular toxicity Injectables
Peripheral neuropathy Linezolid, INH
Quinolones, Ethionamide, Cyloserine
Hepatotoxicity PZA, PAS, Rifabutin, Ethionamide, Quinolones
Renal insufficiency/Electrolyte Injectables
Neuropsychiatric: depression, agitation,
psychosis, difficulty concentrating, insominia
Cycloserine, Quinolones, Ethionamide
Rash All
Visual changes EMB, Rifabutin, Linezolid
Endocrine Ethionamide, PAS
Cardiac: QTc prolongation Bedaquiline, Quinolones, Clofazimine
Strategies for Managing Adverse Reactions
Prior to initiating a treatment regimen discuss the benefits and risks of therapy.
Assure patients that every possible attempt to make their treatment as easy as possible will be made
Stop and substitute another drug if needed and this ispossible– Do not continue an inadequate regimen
Gastrointestinal Upset and Hepatotoxicity
Laboratory testing– Exclude hepatitis and pregnancy
Look for other medical causes
Treatment options– Divide doses
– Anti-emetics
– Tea, food, sea-bands, probiotics
– Low dose anti-anxiety medications
Side Effect Medication
Gastrointestinal
complaints
Ethionamide, PAS
Quinolones,
Clofazmine,
Rifabutin, Linezolid
Hepatotoxicity PZA, PAS, Rifabutin,
Ethionamide,
Quinolones
Hearing Loss/Vestibular dysfunction
Symptoms include tinnitus, fullness in ears, dizziness, unsteadiness– Hearing loss is frequently not reversible
and can progress when medication stopped
Important to have a baseline assessment prior to starting medications
Management– Change dosing schedule
– Stop medication
Side Effect Medication
Hearing loss,
vestibular
toxicity
Injectables
Image from: www.nationalhearingtest.org
Baseline Normal Initial Loss
Progressive loss Speech
Image from: who.int
Neuropathy
More common in patients with diabetes, HIV, pregnancy, hypothyroidism, history of alcohol use, vitamin deficiency
Symptoms: usually symmetric tingling, burning, prickling
Management
– Correct any underlying issues
– Some may be reversible or tolerable for patients
– Lower dose linezolid if symptoms progress with serum drug monitoring
– Gabapentin or low dose tricyclic antidepressant
Side Effect Medication
Peripheral
neuropathy
Linezolid, INH
Quinolones, Ethionamide,
Cyloserine
Summary
Patient will likely have some side effect
Always acknowledge patient’s side effect
Need to balance side effect management with an adequate, effective regimen
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