TB Guidelines

1. Ensure the appropriate indications for use
2. Unique problems faced in the South African Situation.
   
   • Exposure - All of us exposed to tuberculosis at some time
   • Latency – It is crucial to determine the latency status pre use of TNF blockers. Data suggests that in immuno-compromised patients, treatment with prophylaxis can reduce TB by 70% when patients are compliant. Definition and diagnosis of the LATENT state. This Implies treatment is essential
     • Assesment of Lantency
       • Mantoux - the most essential component
         • Equal or More than 5mm = positive (induration.) = latent.
         • To do even in people on treatment with anti TNF at present (but untested as yet.)
         • All new patients to be tested BEFORE anti TNF Rx
         • In pediatrics -If at baseline a negative test is recorded, then we advise retest every 12 months, as this tests for exposure.
         • In adults no data is available re retest. Therefore in adults it is not considered mandatory for a retest.
       • CXR – The main role is especially to hunt for active disease.
     • Treatment choice for latency:
       • INH – RIF combined - The benefit may last longer – in HIV patients, benefit is observed for up to 3 years.
       • INH alone - protected for 1 year in HIV patients.
         • CDC guidelines - Advise INH at least 6 months minimum 9 months desirable.
         • Combination Rifampicin – INH for 3 months, is advised in certain circumstances only. This applies where early initiation of therapy considered absolutely vital i.e. with aggressive disease.
       • Duration of treatment.
         • See clause (a) and (b).
       • Time to start TNF after latency treatment started
         • Information limited. No data available
         • recommend full treatment but practitioner judgement allowed vs. activity of disease
         • INH – RIF regimen may be more useful here as shorter regimen.
       • Monitoring of prophylaxis treatment.
         • Concerns regarding treatment of latent status
         • Hepatotoxicity – more significant in methotrexate co therapy.
           • Liver function testing
             1. ALT at baseline. Minimum testing - MONTHLY if baseline abnormal. 1% of INH patients will get increase in enzymes. Monitor Levels of ALT
                • If >3 x with symptoms – stop
                • If > 5 times without symptoms – stop.
             2. Education of patient regarding symptoms to suggest toxicity – i.e. nausea, vomiting, upper quadrant pain, dark urine..etc.
         • Drug resistance - not considered a problem if TB Rx becomes required.
     • Repetition of screening program
       • There is no evidence in adults of benefit to rescreening the MANTOUX –.
     
     
   • Active disease
     • Must exclude in all cases…as there is absolute contraindication to TNF Rx.
     • To determine if active TB is present
       • If there is a history of previously treated TB – ensure no active disease. Anti TNF Rx is allowed if the patient had > 6 months of full therapy, or the disease was in the distant / remote past. Role for empirical latency treatment in these cases is unclear as there is no data available.
       • Diagnosis of active disease:
         • CXR: If abnormal.
         • Symptoms: Cough > 2 weeks
         • Sputa if obtainable – plus culture (4 weeks.)
     • Treatment in disease whilst on TNF.
       • Diagnosis and Treatment in Patients with TNF drug Rx in situ.
         • Vigilance.
         • Beware of atypical disease / presentation.
         • Extra pulmonary.
         • Unusual histology - poor granuloma formation.
         • STOP TNF drug.
         • No reintroduction until TB therapy completed.
3. Ongoing vigilance in all patients on therapy is required at all times- even if MANTOUX negative