11. RECOMMENDED DRUGS FOR THE TREATMENT OF ADVERSE DRUG REACTIONS
A number of ancillary medications and adjuvant therapies are used to manage ADRs, reduce morbidity and mortality and improve overall treatment outcomes in DR-TB patients.
11.1. Commonly Used Drugs and Supplements
The most commonly used drugs and supplements are:
Headaches are a common adverse effect of DR-TB treatment. It is important to rule out other causes such as meningitis, migraine and cluster headaches. Codeine with acetaminophen gives relief to moderate pain and also helps control cough. Stronger analgesics should be used as appropriate.
The adjuvant use of corticosteroids in patients on DR-TB treatment has been shown not to increase mortality and can help alleviate symptoms associated with severe respiratory insufficiency, central nervous system involvement and laryngeal TB. There is no evidence that one corticosteroid is better than another. Prednisone is commonly used, starting at approximately 1 mg/kg and gradually decreasing the dose by 10 mg per week. Stopping the prednisone abruptly can be dangerous in patients dependent on corticosteroids. Corticosteroids may also alleviate symptoms in patients with exacerbation of obstructive pulmonary disease. In these cases, prednisone may be given over one to two weeks, starting at approximately 1 mg/kg then tapering of the dose by 5-10 mg per day. Patients already using corticosteroids for other conditions should continue their use.
Pyridoxine is given as adjuvant therapy with cycloserine and terizidone to prevent neurological toxicity and should be provided at a dose of 150 mg/day. The dose may be increased to 300 mg/ day when ADRs related to cyloserine or terizidone use are experienced.
Vitamin and mineral supplements
Vitamins (especially vitamin A) and mineral supplements may be given when patients have deficiencies. If minerals are given they should be administered at least one hour before or after administration of fluoroquinolones, as zinc, iron and calcium can interfere with fluoroquinolone absorption.
Oxygen can be used to alleviate shortness of breath. Generally, it is indicated in patients with a pO < 55mmHg or O saturation < 89%, and should be titrated to raise the O Saturation to more than 90%. Oxygen is usually started at 2-4L/min via nasal cannula. If more than 5 L/min is needed, the oxygen should be delivered through a mask. Retention of CO2 can occur in some patients and should be checked when starting oxygen or increasing oxygen delivery. Corticosteroids and morphine also provide significant relief from respiratory insufficiency.
Bronchodilators alleviate shortness of breath and may suppress cough. Due to the high prevalence of residual lung disease in DR-TB patients, bronchodilators should be continued after completion of treatment.
In addition to causing malnutrition, DR-TB can be exacerbated by poor nutritional status. The second-line anti-tuberculosis drugs can also decrease the appetite, making adequate nutrition a greater challenge.
Nutritional support can take the form of providing foods parcels, and whenever possible should include a source of protein.