Treatment of tuberculosis

Management of tuberculosis (TB) should be supervised by specialists. Note though that most patients receive treatment in the community and therefore, primary care health professionals should be familiar with treatment regimens and the associated adverse effects and interactions

• patient adherence to treatment for TB is a major determinant of treatment success
• if there are clinical signs and symptoms consistent with a diagnosis of TB, treatment should be started without waiting for culture results (1)
• the NICE guideline provides guidance based on whether a patient has latent TB (evidence of previous infection and TB is dormant) or have active TB (an ongoing TB related illness such as pulmonary TB)

For people with active TB without central nervous system involvement, offer (1,2):

• isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2months
• then isoniazid (with pyridoxine) and rifampicin for a further 4 months.

Modify the treatment regimen according to drug susceptibility testing

For people with active TB of the central nervous system, offer (1):

• isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2months
• then isoniazid (with pyridoxine) and rifampicin for a further 10 months.

Modify the treatment regimen according to drug susceptibility testing

Adjunctive corticosteroids

• Central nervous system TB
  • at the start of an anti-TB treatment regimen, offer people with active TB of the central nervous system dexamethasone or prednisolone, initially at a high dose with gradual withdrawal over 4-8 weeks
• Pericardial TB
  • at the start of an anti-TB treatment regimen, offer adults with active pericardial TB oral prednisolone at a starting dose of 60 mg/day, gradually withdrawing it 2-3 weeks after starting treatment.

Over 90% of new cases of TB are drug-sensitive and can be treated with standard therapy (1).

• if sputum culture confirms M. tuberculosis but drug sensitivity results are still awaited, the initial phase of treatment should continue until full susceptibility is confirmed, even if this is beyond two months (2)
• if a patient has fully drug-sensitive pulmonary TB the s/he becomes non-infectious within two weeks of commencing treatment (2)
• nearly all forms of extra-pulmonary TB can be treated with the same regimen as for pulmonary TB

Notes (1):

• use fixed-dose combination tablets as part of any TB treatment regimen
• do not offer anti-TB treatment dosing regimens of fewer than 3 times per week
• offer a daily dosing schedule to people with active pulmonary TB
• consider a daily dosing schedule as first choice in people with active extrapulmonary TB
• consider 3 times weekly dosing for people with active TB only if:
  • a risk assessment identifies a need for directly observed therapy and enhanced case management and
  • daily directly observed therapy is not possible
• for people with active spinal TB without central nervous system involvement, do not extend treatment beyond 6 months for residual effects (for example, persistent bending of the spine or vertebral loss)
• disseminated (including miliary) TB
  • patients should be tested for central nervous system (CNS) involvement by:
    • brain scan (CT or MRI) and/or lumbar puncture for those with CNS signs or symptoms
    • lumbar puncture for those without CNS signs and symptoms
    • if evidence of CNS involvement is detected, treatment should be the same as for meningeal TB

Reference:

1. Tuberculosis; NICE Guideline (January 2016 - last updated September 2019)
2. World Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-susceptible tuberculosis treatment. May 2022 [internet publication].