Pharmacotherapy of TB(III) ATT (contd) :Pharmacotherapy of TB(III) ATT (contd) Dr. Rajendra K. Panda, M.D Faculty, Deptt. Of Pharmacology S.C.B. Medical College, Cuttack


Slide 2:RNTCP


RNTCP: Goal & Objectives :RNTCP: Goal & Objectives Goal 1)To decrease mortality and morbidity due to TB 2)To interrupt the chain of transmission in order that TB is no longer a major public health problem in India Objectives 1)To cure at least 85% of new smear positive pulmonary cases; and 2)To detect at least 70% of estimated new smear positive cases existing in the community, after achieving the first objective Strategy is DOTS


RNTCP Can Save More Lives than Any Other Health Intervention :RNTCP Can Save More Lives than Any Other Health Intervention Nearly 5,00,000 people die from TB in India every year — more than 1,400 every day, 1 every minute Most of these deaths could be prevented by effective tuberculosis control Case fatality in the NTP is 5-7 times higher than that of RNTCP


Slide 5:DOTS


Slide 7:The DOTS Strategy (1995) Government commitment to TB control Case detection primarily by smear microscopy mostly on self-reporting symptomatic patients Standardized short-course chemotherapy under proper case management conditions, including DOT Regular/Adequate drug supply Monitoring system for program supervision and evaluation


Directly Observed Therapy (DOT) :Directly Observed Therapy (DOT) What is DOT? DOT is when a health care worker watches a TB patient swallow each dose of the prescribed drugs -Health care worker will conduct DOT at a time and place convenient for the patient


Slide 9:Directly Observed Treatment(DOT) vs DOTS Directly observed treatment (DOT) is one element of the DOTS strategy An observer watches and helps the patient swallow the tablets Direct observation ensures treatment for the entire course with the right drugs in the right doses at the right intervals


Directly Observed Treatment is the Standard of Care :Directly Observed Treatment is the Standard of Care “DOT has emerged as the standard of care” (Bayer, Lancet, 1995) “Every patient with TB in this country should receive DOT” (Iseman, NEJM, 1993) “DOT seems imperative … where the disease has become epidemic” (Chaulk, JAMA, 1996)


Slide 11:Why is it necessary to directly observe treatment? At least one third of patients receiving self-administered treatment do not adhere to treatment Impossible to predict which patients will take medicines DOT is necessary at least in the initial phase of t/t to ensure adherence and achieve sputum smear conversion A TB patient missing one attendance can be traced immediately and counseled


Benefits of DOTS :Benefits of DOTS Produces cure rates of up to 95 % Prevents new infections Prevents the development of MDR-TB Cost effective


DOTS can reduce the burden of TB :DOTS can reduce the burden of TB Annual percentage decline in incidence/prevalence


Slide 14:DOTS triples t/tsuccess in S. East Asia


DOTS can reduce drug resistance :DOTS can reduce drug resistance Decline (percent)


Treatment Categories :Treatment Categories


Slide 17:Severe and less severe forms of extra-pulmonary TB TB/HIV, A Clinical Manual, World Health Organization 1996 Skin


Case definition by previous treatment (I) :Case definition by previous treatment (I) New case: a patient who has never taken anti-TB drugs for more than 1 month. Relapse: -previously received treatment, -from any source -Declared cured, -& has once again ss(+) PTB. Failure: a TB patient who while on treatment remains ss(+), at 5th month or later, or was ss(-) at start and becomes ss(+) after 2nd month of treatment.


Case definition by previous treatment :Case definition by previous treatment Return after interruption (default): a patient who completed at least 1 month of treatment, from any source and returned after at least 2 months’ interruption of treatment with ss(+),clinically active TB. Transfer in: registered for treatment in one district who transfers to another district where he/she continues treatment. Chronic: remains ss(+) after 1 re-treatment


Recommended treatment regimens :Recommended treatment regimens Direct observation is recommended for all patients and is particularly essential when intermittent regimens are used


Recommended treatment regimens :Recommended treatment regimens


Doses of first-line anti-TB drugs :Doses of first-line anti-TB drugs All these anti-TB drugs can be given as a single daily dose. Direct observation is recommended for all patients and is particularly essential when intermittent regimens are used. Thiacetazone is not effective when given intermittently and is not recommended for use in high HIV prevalence areas.


DOTS in the context of HIV :DOTS in the context of HIV DOTS can: Prolong life and improve its quality Stop the spread of TB Prevent emergence of MDRTB Reverse the trend of MDRTB Failure to use DOTS in the face of HIV can lead to explosive spread of TB, with cases tripling and drug resistance increasing rapidly


Treating TB &HIV together :Treating TB &HIV together Possible Options are: 1)Defer ART till completion of TB t/t 2)Defer ART until end of Initial phase( at least 15days ) & use E&H in the cont.phase. 3)T/t TB with R containing regimen and use EFV + 2 NRTI 4)T/t TB with R containing regimen & use 2NRTI & change to max.supressive HAART on completion of TB t/t


Newer Policy Response to MDR-TB - DOTS-Plus :Newer Policy Response to MDR-TB - DOTS-Plus Government commitment Bacteriologically confirmed diagnosis (generally includes culture and drug susceptibility testing) Observed standardized and/or individualized multidrug regimens Regular, uninterrupted supply of quality second-line drugs and diagnostic materials Systematic monitoring and evaluation of program activities


Suggested Regimen: :Suggested Regimen:


Role of Steroids in TB :Role of Steroids in TB In seriously ill pt/miliary/severe PTB When h/s reaction occurs with ATT An AIDS patients with severe menifestation In meningeal/renal tb/pleural effusion C/I- INTESTINAL TB (Silent perforation)


Effective Diagnosis, Treatment, and Control of Tuberculosis :Effective Diagnosis, Treatment, and Control of Tuberculosis World Health Organization Regional Office for South-East Asia New Delhi


Stop TB Strategy, 2006 :Stop TB Strategy, 2006 Vision: A world free of TB Goal: To dramatically reduce the global burden of TB by 2015 in line with Millennium Development Goals and the Stop TB Partnership targets


Conclusion: :Conclusion: DOTS is the BEST strategy we have for controlling TB now AND The most contentious part of DOTS – is to DO it


Slide 32:Thank You