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

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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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