Session xx: - I-TECH TB Prevention Toolkit

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Session 6: Isoniazid Preventive
Therapy (IPT), Part I: Patient
Eligibility and Preparation
Introduction
• TB is the leading cause of death among
PLHIV
• Isoniazid Preventive Therapy (IPT) is used
to prevent TB among PLHIV who do not
have TB disease and meet eligibility
criteria for IPT
• IPT is one of the 3 I’s strategies to reduce
the burden of TB among PLHIV
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 2
Learning Objectives
• By the end of the session, participants
should be able to:
•
•
•
•
•
Explain the rationale for IPT
Determine which patients are eligible for IPT
Explain and prepare patients for IPT
Describe how to start and monitor IPT
Manage common side effects associated with
IPT
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 3
Rationale for IPT (1)
• Aim of introducing IPT to PLHIV is to prevent
active TB in patients who do not have it
• WHO/UNAIDS recommends use of IPT for
PLHIV in areas where co-infection is > 5%
• An estimated 10-15% of PLHIV have active
TB disease
• Over 30% of AIDS-related deaths among
adults are due to Tuberculosis
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 4
Rationale for IPT (2)
• MOHSW Policy statement for IPT
• Health facilities (H/F) with sufficient capacity will
be accredited to offer IPT in strict compliance with
national and international guidelines
• INH will be provided to eligible patients free of
charge in accredited H/F
• MOHSW will:
• develop a procurement and logistical management plan
for sustainable provision and supply of INH at service
delivery points
• be the accrediting body and regularly monitor and
evaluate IPT use in the country
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 5
Purpose of Using IPT
• IPT is aimed at decreasing the risk of a
first or recurrent episode of TB
• Among PLHIV, IPT is likely to provide
protection against the risk of developing
TB by decreasing the risks of:
• Progression of recent infection
• Reactivation of latent M. Tuberculosis
• IPT programs decrease rate of TB in the
community and improve TB control
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 6
Role of IPT in Preventing TB Disease
Early progression (5%)
IPT
Infection (30%)
Inadequate
Immunological
Defenses
Late progression(5%)
Inadequate
IPT
Immunologic
Defenses
Adequate
I.C.
Adapted from Phil Hopewell
Containment (95%)
Adequate
Exposure
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Continued containment (90%)7
How Long Does IPT Work?
• The IPT prevention effect against TB lasts
for 1–2 years after the 6-9 month course
and then the risk of TB gradually returns
because of new exposures
• After 1-2 years, re-infection may occur and
secondary IPT is recommended
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 8
PLHIV Eligible for IPT
Who Should Receive IPT
in Tanzania?
• People at high risk for TB such as:
• HIV exposed and unexposed infants of mothers
with pulmonary TB
• All children <5 yrs in contact with smear positive
TB patient
• All persons who are HIV positive and in particular
those who are:
•
•
•
•
•
Family members of a sputum smear positive TB patient
Prisoners
Hospitalized patients and outpatients
Health care workers
Individuals in congregate settings
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 10
IPT Exclusion Criteria (1)
• Exclusion:
• TB suspect / patient with confirmed active TB
disease
• Patient currently on TB treatment and those
with history of completed TB treatment and/or
IPT in the past 2 years*
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 11
IPT Exclusion Criteria (2)
• Medical contraindications to INH* (current
or prior)
• Intolerance/allergy to INH
• Chronic/acute liver disease
• Alcohol abuse
• Poor compliance / adherence
• Terminal AIDS stage 4 (as per WHO
palliative care definition)
• Pregnant mothers
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 12
Inclusion Criteria for IPT
• Those who are eligible for IPT:
• Have been documented as HIV positive
• Are fifteen years of age and above
• Do not meet any of the exclusion criteria
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 13
Case Study 1:
Assessing Eligibility for IPT
• Malika is a 41 year old teacher who is referred to
CTC after having been diagnosed HIV-positive
at VCT. She is very woried about her health
since she has two young children under 5 whose
HIV status is unknown. She does not report
signs and symptoms of tuberculosis
• How would you assess this patient for TB?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 14
Case Study 1 (continued)
Tick appropriate response
Do you have the following:
• Cough for ≥ 2 weeks?
• Coughing up bloodstained
sputum (haemoptysis)?
• Fevers for ≥ 2 weeks?
• Noticeable weight loss for new
patients or a 3 kgs weight loss in
a month (subsequent visit)?
• Excessive sweating at night
for ≥ 2 weeks?
yes
no
□
√
□
√
□
√
□
√
□
√
....... this patient is HIV-positive but she is
apparently “healthy”!
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 15
Case Study 1 (continued)
HIV-infected patient with ALL answers NO on the
TB questionnaire
No need to undertake AFB microscopy
This patient is considered an asymptomatic PLHIV.
Therefore:
Assess for IPT eligibility
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 16
Case Study 2: Assessing Eligibility
for IPT
• Maisha is a 39 year old taxi driver from
Kabwete and has been living with HIV for
3 years. On this visit to the Kabwete CTC
he complains of fever and cough which
have lasted for the past 3 weeks. Upon
further questioning, he admits to having
lost 3 kg in the last month.
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 17
Case Study 2 (continued)
Tick appropriate response
Do you have the following:
• Cough for ≥ 2 weeks?
• Coughing up bloodstained
sputum (haemoptysis)?
• Fevers for ≥ 2 weeks?
• Noticeable weight loss for new patients
or a 3 kgs weight loss in a month
(subsequent visit)?
• Excessive sweating at night
for ≥ 2 weeks?
yes
√
□
√
no
□
√
□
√
□
□
√
.....This patient has several signs/ symptoms
that qualify him to be a “TB suspect”
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 18
Sputum Request Form
MOHSW Tanzania
• If you suspect
TB in a patient,
use the sputum
request form to
refer the patient
to the lab for a
sputum test
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
19
Case Study 3
• Fatim is a 34 year old police officer who
has been attending another CTC but was
recently transfered to the city. As a new
patient to your clinic, you decide to assess
her TB status.
• How will you introduce the subject of TB
screening?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 20
Case Study 3 (continued)
• Upon further discussion with Fatim, you
discover that she has had a fever for about
10 days. Her weight is 48 kg and she
looks a little wasted. She knows that her
weight was 55 kg 3 months ago. She
denies having a cough but says she has
chest pain. She has no memory of ever
having had an opportunistic infection.
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 21
Case Study 3: What Are the Next
Steps?
• You discover the following additional
information while you are discussing her
case:
•
•
•
•
Physical examination is negative
Hb: 10.3
CD4: 180 (1 week ago)
She is not on ART
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 22
TB Screening Questionnaire
Tick appropriate response
Do you have the following:
Cough for ≥ 2 weeks?
Coughing up bloodstained
sputum (haemoptysis)?
Fevers for ≥ 2 weeks?
Noticeable weight loss for new patients
or a 3 kgs weight loss in a month
(subsequent visit)?
Excessive sweating at night
for ≥ 2 weeks?
yes
□
no
√
□
□
√
□
√
□
√
√
Hmm!!! This patient has borderline symptoms
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 23
Case Study 3: Next Steps?
• Does the patient have active TB?
• Do you think it is relevant to investigate
the patient’s and relatives’ history?
• Findings:
•
•
•
•
AFB microscopy test: negative (saliva seen)
CXR: negative for active TB
Patient does not report history of past TB
The patient’s father who stays at her home is
on TB treatment
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 24
Case Study 3: Conclusions
•
•
•
•
•
What is your conclusion?
Does the patient have TB?
If yes, would you start TB treatment?
Otherwise, is the patient eligible for IPT?
Do you suggest to conduct additional
investigations?
• How do you plan the follow-up?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 25
Before initiating preventive
therapy, active TB must be
excluded!
• Due to the increased rate of smear
negativity in HIV-infected individuals, a
chest radiograph is necessary in addition
to a negative sputum smear to exclude
active TB with any certainty
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
26
Assessment of IPT Eligibility
IPT Algorithm -1
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
28
IPT Algorithm - 2
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Counselling
29
Preparation of the Patient for
IPT
Adherence Education and
Counseling Flow Chart
PLHIV is eligible to start IPT
PLHIV is referred to
Adherence Nurse
Pre-IPT Adherence Counselling
1.
2.
3.
4.
5.
6.
7.
8.
Assess patient’s knowledge of HIV and TB
Recommend Treatment Assistant
Educate patient about the relationship between HIV and TB
Educate about importance of IPT
Explain drug regimen, side effects and importance of adherence
Identify barriers to adherence and strategies to overcome barriers
Assess patient’s readiness to start IPT
Document in Adherence checklist
Source: SOP for HIV care and treatment – NACP MOHSW Tanzania
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
31
Prescribing IPT
• Write down the dose and duration of INH
• Dose: 300 mg daily
• If patient weighs <30 kg: dose 5 mg/kg
• Duration: 6 months
• Pyridoxine
• Dose: 25 mg daily
• Duration: 6 months
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 32
What is Considered Good IPT
Adherence?
• An uptake of 80% or more of the total
doses of IPT is enough to achieve the
protective effect
• At the end of 6 months, patient should
have taken 180 pills (which =100%)
• If patient has not taken at least 80% (144
doses), then needs to continue on IPT to
complete the total within a maximum time
of 9 months
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 33
Group Discussion:
How Do You Assess Whether
Your Patients Are Adherent?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 34
Follow Up Visits
• Give dates for follow up appointments at monthly
follow up (whether PLHIV on ART or in care)
• At the follow up visit:
•
•
•
•
Assess adherence
Continue counselling/continuous education
Assess for side effects
Screen for development of active TB (even if patient
is on IPT)
• Check for signs and symptoms of TB
• Use screening tool
• Check drug supplies
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 35
Remember: It is Still Possible to
Miss TB During IPT
• In a study done in Tanzania, it was found
that of the 93 patients studied, 14 (15%)
had active TB of which:
• 10 (71%) had clinical TB (symptoms or chest
radiograph findings)
• 4 (29%) had subclinical TB (positive sputum
AFB stain or culture results but no symptoms
or chest radiograph findings)
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 36
Assessing Adherence
•
•
•
•
Patient self-report
Detailed interview
Pill counts
Pharmacy refill data
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 37
Role Play Activity
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 38
Case Study: Adherence During IPT
• 38 year old HIV-positive male at the end of
the 2nd month of IPT travels to a relative’s
funeral without informing the CTC staff.
Before leaving, he takes the last 4 tablets
of INH. One month later he comes back to
the CTC reporting having missed doses
for the past 4 weeks.
• What action will you take?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 39
Other Challenges to IPT
Implementation
• For patients, the following may affect
success of IPT programs:
• Financial barriers affecting travel to collect
drug supply leading to missed appointments
• Secrecy and stigma with PLHIV who fear
being seen collecting medications
• Fears of being on the drug for a long time
• Fear of side effects, based on experiences of
peers
• Inadequate access to food
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 40
Adherence Support Strategies
for IPT Programmes
Adherence Support
•
•
•
•
•
Patient education and counselling
Access to uninterrupted medication supply
Medication reminders
Medication partners
Ongoing support and reinforcement
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 42
Patient Education and Counselling
• Patient education should take place prior
to IPT initiation, but should also continue
throughout the course of IPT use
Remember,
adherence may decrease over time
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 43
Ensuring Uninterrupted Supply of
IPT
• Ensure that patients understand where,
when, and how to obtain medications
• Avoid “stock outs” by accurately balancing
needs and consumption
• Assist patients to safeguard medicines
• Provide access to care to patient’s
household, limiting pressures to share
medicines
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 44
IEC and Peer Educators
• Educate patients and the public on TB
• Use TB patients or those who have been
on IPT to educate other patients
• Use the support of peer educators to
conduct counselling/education for PLHIV
on IPT
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 45
Side Effects of INH
Side Effects and Management
Side Effect
Mild
-Tingling/ burning sensation
- Joint pain
- Mild skin rash
-Abdominal pain
Severe - Hepatitis/ jaundice
- Severe skin rash with
peeling skin
- Disabling peripheral
neuropathy
- Convulsions
Session 6 Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Management
Continue with
INH
Reassure
Reassess
STOP INH
Refer for further
management
47
Concurrent Use of Herbs
• There is potential for interaction between
herbs and INH
• Unless the components of the herbs are
known, concomitant use should be
discouraged
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 48
Case Studies on Side Effects
Case Study 1
• 56 year old HIV-positive man started IPT 3
weeks ago - dose of 300 mg/day. He
comes back to CTC complaining of itching
skin lesions on upper body for 5 days
• He has no other signs/symptoms
• Clinical examination shows rash, no ulcers
• Is this due to drug toxicity or another acute
illness?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 50
Case Study 1 (Continued)
• Upon taking additional history you
discover that he has also taken traditional
medicine to cure the rash, with no benefit.
The patient is not taking any other drug
and is not on ART. The patient has never
reported any similar signs or symptoms
before
• Is this problem due to the traditional
medicine?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 51
Case Study 2
• 28 year old HIV-positive Mariam was
started on IPT 2 months ago at a dose of
300 mg/day. She is not taking Pyridoxine
because it was out of stock at the
pharmacy. She returns to CTC
complaining of numbness of the toes.
• What is your diagnosis?
• What is the differential diagnosis?
• What other questions would you ask?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 52
Case Study 2 (continued)
• The patient is not diabetic, does not drink
alcohol and eats well. No other drugs
have been taken (the patient is not on
ART; CD4=320)
• Does the patient have peripheral
neuropathy? Or is it something else?
• Do you think it is caused by INH?
• Is the time course consistent?
• Should the IPT be stopped?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 53
Development of TB during IPT (1)
• Although a small proportion of patients on
IPT may develop active TB disease, there
are public health consequences to this
therefore it is important to keep reassessing for active TB at every visit
• Remember to repeat TB screening
questionnaire at every follow up visit!
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 54
Development of TB during IPT (2)
Overall Guidance:
1) Stop IPT
2) Start anti-TB medication
3) Substitute NVP with EFV (if on
NVP-containing ART regimen)
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 55
PLHIV on IPT Develops Active TB
After Starting ART
TB
Type of TB
occurrence
Management of ART
Within 6
months of
starting ART
Stop IPT. If already on EFV: continue
If on NVP; substitute with EFV
Start TB treatment
Any
After 6 months PTB or EPTB lymph
of ART
nodes of uncomplicated
pleural TB without clinical
and/or immunological
evidence of disease
progression
EPTB other than types
listed above
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Stop IPT. Continue ART regimen
switching to EFV and re-assess the
patient at completion of TB treatment
If already on EFV: continue
If on NVP; substitute with EFV
Start TB treatment
Stop IPT. Start TB treatment
Consider as ART failure and switch
to 2nd line regimen
Slide 56
Use of INH and ART in PLHIV in
Stages 3 and 4 (1)
Logistics and
advantages:
• ART indicated in such
patients
• INH may be more
useful for stage 3 or 4
patients (with no TB)
• For those on ART, the
regular follow-up for
HIV C&T should also
address adherence to
INH
Problems:
• May be difficult to
exclude TB in these
patients, especially
stage 3 disease
• INH may add to toxicity
of ARV drugs,
especially Stavudine
(d4T), Didanosine (ddI)
• Extra pills to take and
this may compromise
adherence
Consider drug-drug interactions BUT these
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility
and Preparation
should
not delay or interrupt IPT!
Slide 57
Use of INH and ART in PLHIV in
Stages 3 and 4 (2)
• New symptoms in patients with advanced
HIV who are on IPT and start ART may be
due to:
•
•
•
•
Immune reconstitution syndrome (IRIS)
Active TB
Other OIs
Side effects of ART
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 58
Protocol for Managing IRIS
• Investigate for OI and manage accordingly
• Give adequate fluids, intravenously if possible
• If available, offer NSAIDs for control of mildmoderate fever, inflammation, and pain
• Do not stop IPT, unless IRIS is severe or TB is
diagnosed
• Do not stop ART, unless IRIS is severe
• Add steroids if reaction is severe (according to
national guidelines)
• Counsel patient, caregiver and treatment assistant
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 59
Case Study 3
• 37 year old HIV-positive woman started 3TC +
d4T + NVP six weeks ago. She is eligible for
IPT and starts INH 300 mg/day
• 10 days later she comes back to the CTC
complaining of abdominal pain and tiredness.
She is jaundiced and looks dehydrated. She
has right upper quadrant tenderness on
abdominal examination
• What is the possible cause of these findings?
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 60
Nevirapine and Hepatotoxicity
• In addition to rash (the most common side
effect), NVP may cause hepatotoxicity which
can, in rare cases, be severe
Possible causes
Side effect
Hepatitis
Anti-TB drugs
ARV drugs
PZA
RIF
INH
NVP
PI
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 61
Risk Factors for Developing
Hepatotoxicity
• Baseline elevation of AST or ALT
• Chronic viral hepatitis (HBV, HCV)
• Alcohol abuse
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 62
Normal Liver Enzymes
Upper limit of normal (ULN) for ALT
• Male
10-40 U/L
• Female
7-35 U/L
Upper limit of normal (ULN) for AST
• Male
15-40 U/L
• Female
13-35 U/L
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 63
Grading Hepatotoxicity
For patients with normal pre-treatment AST
and ALT
• Grade 0: < 1.25 x upper limits of normal
• Grade 1: 1.25-2.5 x upper limits of normal
• Grade 2: 2.6-5 x upper limits of normal
• Grade 3: 5.1-10 x upper limits of normal
• Grade 4: > 10 x upper limits of normal
AIDS Clinical Trial Group Scale
Management of Hepatotoxicity depends
on the grade
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 64
Case Study 3 (continued)
• The following tests are then performed for
this patient with the following results....
Lab
Hb=11.2 ALT= 303, AST=405
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 65
Hepatotoxicity Management
• Grade 0-2: Continue ARVs and IPT, monitor
closely
• Grade 3-4: Discontinue ART and IPT
• Stop all three antiretroviral drugs
• Monitor closely (clinical and laboratory
monitoring)
• Wait until symptoms and laboratory abnormalities
resolve
• Start new ART regimen (without NVP) and restart INH
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 66
Management of Skin Rash (1)
• If rash is mild:
• Give antihistamine and
continue with IPT
• Monitor closely, do
LFTs
• Prednisolone
40mg/day may be
given until rash clears
• then taper dose
gradually before
complete stop
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
• If severe rash occurs:
• STOP IPT immediately
• START high dose
steroid e.g.
prednisolone 6080mg/day
• if oral medication not
possible, give IV
dexamethasone or
hydrocortisone
Slide 67
Management of Skin Rash (2)
• Give antihistamines
• Manage other symptoms, e.g. pain, with
analgesics
• Admit patient to hospital for observation, or
refer as needed
• Consider IV fluids, especially if there is
Stevens-Johnson Syndrome
• Consider antibiotics e.g. cloxacillin if
secondary bacterial infection is suspected
• Monitor carefully and do LFTs
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 68
IPT in Pregnancy
• Pregnancy is not a contraindication to IPT
but should be deferred until the
postpartum period
• IPT can be started as soon as the first
postpartum visit (6 weeks PP)
• IPT is safe during lactation
• Source: Snider; Francks 1988, Thompson Micromedex online
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 69
Key Points (1)
• IPT is aimed at decreasing the risk of a first
or recurrent episode of TB
• IPT should only be prescribed when it is
possible to rule out active TB
• Consider other IPT exclusion criteria before
initiation
• Adherence is essential for IPT effectiveness
• IPT side effects should be managed in order
to improve adherence
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 70
Key Points (2)
• Given that IPT could still cut number of active TB
cases by 30 to 50%, a slight increase in
resistance is still not a good excuse to prevent
roll-out of IPT
• However, it does suggest that more attention
should be given to optimizing the screening
process – to reduce the number of active TB
cases that are missed – and to the management
of people with breakthrough disease
• When active TB occurs among those given IPT,
the recommended initial treatment regimen for
treatment remains RHZE
Session 6: Isoniazid Preventive Therapy (IPT), Part I:
Patient Eligibility and Preparation
Slide 71
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