A quick reference to drugs commonly used in the management of TB

NAME

RIFAMPICIN (Bactericidal, Sterilizing)

DOSE/KG

10 mg/kg/day

USUAL DOSE

600 mg dly

MAXIMUM DOSE

600 mg dly

CAUTION

Hepatic disease, alcoholism, porphyria, hypersensitivity to Rifampicin

COMMON SIDE EFFECTS

↑ ALT, GI , Hypersensitivity, Orange discoloration of body fluids

PAEDIATRIC DOSE

10 mg/kg/day (up to 20 mg/kg/day for TBM/Miliary TB)

RENAL DOSE

N/A

LIVER IMPAIRMENT DOSE

8 mg/kg/day

PREGNANCY

Category C

LACTATION

Amount excreted too small to harm

BUILDING A REGIMEN

High early bactericidal activity. With Isoniazid achieves greater killing than either drug alone. Resistance more rare than Isoniazid resistance

NAME

ISONIAZID (Bactericidal)

DOSE/KG

5 mg/kg/day (10 mg/kg/day = High dose INH)

USUAL DOSE

300 mg dly

MAXIMUM DOSE

300 mg dly

CAUTION

Hepatic disease, Epilepsy, hypersensitivity to Isoniazid, porphyria

COMMON SIDE EFFECTS

Skin rash, peripheral neuropathy, ↑ ALT, neurotoxicity, haematological effects

PAEDIATRIC DOSE

5-10 mg/kg/day (up to 15 mg/kg/day for TBM/Miliary TB)

RENAL DOSE

N/A

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Category C

LACTATION

Monitor infant for adverse effects

BUILDING A REGIMEN

Highest early bactericidal activity. With Rifampicin achieves greater killing than either drug alone. Strain of TB may still be susceptible in certain cases of resistance depending on mutation

NAME

PYRAZINAMIDE (Sterilizing)

DOSE/KG

20-30 mg/kg/day

USUAL DOSE

1600 mg dly

MAXIMUM DOSE

2 g dly

CAUTION

Gout, Hepatic disease, Diabetes, Renal impairment, hypersensitivity to pyrazinamide, isoniazid, ethionamide or niacin, porphyria

COMMON SIDE EFFECTS

Hepatotoxicity, arthralgia (hyperuricaemia), GI side effects, skin rash

PAEDIATRIC DOSE

15-30 mg/kg/day (up to 40 mg/kg/day for TBM/Miliary TB)

RENAL DOSE

Use doses at lower limit of recommended range. GFR<10 ml/min - ↓dose by 50%

LIVER IMPAIRMENT DOSE

Avoid drug if possible

PREGNANCY

Category C

LACTATION

No problems with usage

BUILDING A REGIMEN

Good sterilizing activity, contributes to shortening of duration of treatment. Resistance not tested routinely

NAME

ETHAMBUTOL (Bacteriostatic, may be bactericidal at high doses)

DOSE/KG

15-20 mg/kg/day

USUAL DOSE

800 mg dly

MAXIMUM DOSE

1000 mg dly

CAUTION

Eye defects, renal disease or hyperuricaemia

COMMON SIDE EFFECTS

Ocular toxicity, arthralgia (hyperuricaemia), GI side effects

PAEDIATRIC DOSE

15-25 mg/kg/day (up to 15 mg/kg/day for TBM/Miliary TB)

RENAL DOSE

GFR <10 ml/min – 15 mg/kg every 48 hours

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Max 15 mg/kg/day

LACTATION

No known adverse effects

BUILDING A REGIMEN

NAME

ETHIONAMIDE (Bacteriostatic)

DOSE/KG

15-20 mg/kg/day

USUAL DOSE

1000 mg dly (Split dose 250 mg mane, 750 mg nocte to minimize nausea)

MAXIMUM DOSE

1000 mg dly

CAUTION

Hepatic disease, previous hypersensitivity to Ethionamide or porphyria. Use with caution in diabetes, alcoholics, psychiatric illness, depression, hypothyroidism and epilepsy

COMMON SIDE EFFECTS

GI side effects, CNS toxicity, Hepatotoxicity

PAEDIATRIC DOSE

10 mg/kg/day

RENAL DOSE

GFR <30 ml/min or on dialysis – Decrease dose by 50%

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Category C. Teratogenic in animals. Avoid

LACTATION

Safety not established

BUILDING A REGIMEN

NAME

CYCLOSERINE (AND TERIZIDONE – a derivative of Cycloserine) (Bacteriostatic)

DOSE/KG

10-20 mg/kg/day. + Pyridoxine to prevent CNS Side effects

USUAL DOSE

500-750 mg dly or 250-500 mg bd

MAXIMUM DOSE

1000 mg dly

CAUTION

Contraindicated in psychiatric conditions, epilepsy, severe renal impairment, alcohol abuse and porphyria. Caution in elderly and those with renal impairment

COMMON SIDE EFFECTS

CNS toxicity (more common with Cycloserine), skin rash

PAEDIATRIC DOSE

10 mg/kg/day

RENAL DOSE

Extend dose interval and adjust by monitoring drug levels (Target – 20-30micromg/ml)

GFR 10-50 ml/min – Extend dosing interval to 24 hrs

GFR <10 ml/min – Extend dosing interval to 36-48 hrs

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Use only if no alternatives

LACTATION

Give infant Pyridoxine

BUILDING A REGIMEN

Does not share cross-resistance with other anti-TB drugs

NAME

PARA-AMINO SALICYLIC ACID (PAS)

DOSE/KG

150 mg/kg/day or 10-12 g/day in 2 divided doses

USUAL DOSE

5 g bd

MAXIMUM DOSE

12 g/day

CAUTION

Allergy to aspirin or PAS. Avoid in advance renal impairment

COMMON SIDE EFFECTS

Anorexia, diarrhoea, hypothyroidism. Low risk of hepatitis

PAEDIATRIC DOSE

150 mg/kg/day in 2 or 3 divided doses

RENAL DOSE

Avoid

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

Concentrations excreted in breast milk are low

BUILDING A REGIMEN

NAME

LEVOFLOXACIN (Bactericidal)

DOSE/KG

-

USUAL DOSE

750 mg dly

MAXIMUM DOSE

750 mg dly

CAUTION

As for Ciprofloxacin

COMMON SIDE EFFECTS

As for Ciprofloxacin.

PAEDIATRIC DOSE

7.5-10 mg/kg/day (Max 750 mg)

RENAL DOSE

GFR <30 ml/min – 750-1000mg 3 times/week

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

Avoid

BUILDING A REGIMEN

NAME

OFLOXACIN (Bactericidal)

DOSE/KG

-

USUAL DOSE

800 mg dly or 400 mg bd

MAXIMUM DOSE

800 mg dly

CAUTION

Avoid in patients with prolonged QT interval. Previous hypersensitivity to fluoroquinolones. Caution in patients with CNS disorders, hepatic or renal involvement and in children

COMMON SIDE EFFECTS

GI side effects, Headaches, dizziness, drowsiness, insomnia, arthralgia. Hypersensitivity

PAEDIATRIC DOSE

15-20 mg/kg/day

RENAL DOSE

GFR <30 ml/min – 800 mg 3 times/week

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

Avoid

BUILDING A REGIMEN

NAME

CIPROFLOXACIN (Bactericidal)

DOSE/KG

-

USUAL DOSE

500-750 mg bd (Doses at higher range preferred in TB)

MAXIMUM DOSE

750 mg bd

CAUTION

Avoid in patients with prolonged QT interval. Previous hypersensitivity to fluoroquinolones. Caution in patients with CNS disorders, hepatic or renal involvement and in children

COMMON SIDE EFFECTS

GI side effects, Headaches, dizziness, drowsiness, insomnia, arthralgia. Hypersensitivity

PAEDIATRIC DOSE

20-30 mg/kg/day in 2 divided doses

RENAL DOSE

GFR <30 ml/min – 1000-1500 mg 3 times/week

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

Avoid

BUILDING A REGIMEN

NAME

MOXIFLOXACIN (Bactericidal)

DOSE/KG

-

USUAL DOSE

400 mg dly

MAXIMUM DOSE

400 mg dly

CAUTION

As for Ciprofloxacin

COMMON SIDE EFFECTS

As for Ciprofloxacin

PAEDIATRIC DOSE

7.5-10 mg/kg/day (Max 400 mg)

RENAL DOSE

No dose adjustment

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

Avoid

BUILDING A REGIMEN

NAME

STREPTOMYCIN (Bactericidal)

DOSE/KG

15-20 mg/kg/day IMI

USUAL DOSE

750 mg dly IMI

MAXIMUM DOSE

1000 mg dly IMI

CAUTION

Patients with renal failure, impaired hearing or vestibular defects, previous hypersensitivity to Streptomycin. Contraindicated in myasthenia gravis

COMMON SIDE EFFECTS

Ototoxicity, renal toxicity, hypersensitivity, skin rash

PAEDIATRIC DOSE

20-40 mg/kg/day

RENAL DOSE

GFR 10-50 ml/min – 15 mg/kg every 24-72 hours

GFR <10 ml/min – 15 mg/kg every 72-96 hours

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Can cause ototoxicity in foetus – avoid

LACTATION

No known adverse effects

BUILDING A REGIMEN

NAME

KANAMYCIN (Bactericidal)

DOSE/KG

15 mg/kg/day IMI

USUAL DOSE

750-1000 mg dly IMI

MAXIMUM DOSE

1500 mg dly IMI

CAUTION

Patients with renal failure, impaired hearing or vestibular defects, previous hypersensitivity to Kanamycin. Contraindicated in myasthenia gravis

COMMON SIDE EFFECTS

Ototoxicity, renal toxicity, hypersensitivity, skin rash

PAEDIATRIC DOSE

15-30 mg/kg/day

RENAL DOSE

GFR <30 ml/min – 12-15 mg/kg 2-3 times/week

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

No known adverse effects

BUILDING A REGIMEN

Vs Amikacin - As effective, less well tolerated, cheaper

Vs Streptomycin - Streptomycin-resistant strains usually susceptible to Kanamycin and Amikacin

NAME

AMIKACIN (Bactericidal)

DOSE/KG

15-20 mg/kg/day IMI

USUAL DOSE

750-1000 mg dly IMI

MAXIMUM DOSE

1500 mg dly IMI

CAUTION

Patients with renal failure, impaired hearing or vestibular defects, previous hypersensitivity to Amikacin. Contraindicated in myasthenia gravis. Caution in neonates

COMMON SIDE EFFECTS

Ototoxicity, renal toxicity, peripheral neuropathy, hypersensitivity, skin rash

TARGET DRUG LEVELS

Peak > 30 mg/L; trough < 1 mg/L

PAEDIATRIC DOSE

<10 years – 25 mg/kg dly on first day; then 18 mg/kg dly

>10 years – 20 mg/kg dly on first day; then 15 mg/kg dly

RENAL DOSE

GFR <60 ml/min – Loading dose 10 mg/kg with further doses guided by drug levels

LIVER IMPAIRMENT DOSE

N/A

PREGNANCY

Avoid

LACTATION

No known adverse effects

BUILDING A REGIMEN

Vs Kanamycin – As effective, better tolerated, more expensive

Vs Streptomycin - Streptomycin-resistant strains usually susceptible to Kanamycin and Amikacin