Latent tuberculosis infection (LTBI) treatment recommendations
Centers for Disease Control and Prevention (CDC) and the American Thoracic Society have issued
revised treatment guidelines for treatment of latent tuberculosis
infection after investigating 23 reports of severe liver injury associated
with the rifampin and pyrazinamide regimen. Seventeen (17) of the patients
survived and 6 died. While latent TB (LTBI) treatment is generally
well-tolerated, health care providers and their patients should be aware
of rare life-threatening side effects and use any medication regimen with
caution. The revised treatment guidelines for LTBI should limit the
circumstances in which the combination of rifampin and pyrazinamide (RIF-PZA)
is prescribed and strengthen the level of patient counseling and
monitoring recommended for LTBI treatment regimens.
considerations when using
RIF-PZA for LTBI treatment
- Patients should be counseled about the risks and
benefits of latent TB treatment and monitored closely.
- Nine months of an isoniazid (INH) regimen should
be used when feasible.
- Use rifampin and pyrazinamide with caution in
persons at high-risk for TB disease who are unlikely to complete a
- Exercise extreme caution when using a rifampin
and pyrazinamide (RIF-PZA) regimen in those with a history of
alcoholism or those who are currently taking medications associated
with liver injury.
- RIF-PZA is NOT recommended for persons with
underlying liver disease or for those who have had INH-associated
- The PZA dose in the RIF-PZA regimen should be
<20 mg/kg per day with a maximum of 2 grams daily
- No more than a 2 week supply of RIF-PZA should be
delivered to the patient to facilitate periodic clinical assessments.
- Patients taking RIF-PZA should be reassessed in
person by a health-care provider at 2, 4, and 6 weeks of treatment for
adherence, tolerance, and adverse effects. At each visit, health-care
providers conversant in the patient's language should instruct the
patient to stop taking RIF-PZA immediately and seek medical
consultation if abdominal pain, emesis, jaundice, or other hepatitis
symptoms develop. Provider continuity is recommended for monitoring.
- Serum aminotransferase (ASTand/or ALT) and
bilirubin should be measured at baseline and at 2, 4, and 6 weeks of
treatment in patients taking RIF-PZA.
- Treatment should be stopped and not resumed for
any of these findings: aminotransferase (AST or ALT) greater than five
times the upper limit of normal range in an asymptomatic person,
aminotransferase (AST or ALT) greater than normal range when
accompanied by symptoms of hepatitis, or a serum bilirubin greater
than normal range.
- Patients taking RIF-PZA should be reassessed at 8
weeks to document treatment completion.
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March 26, 2014