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The Medical Letter publications are protected by US and international copyright laws. Forwarding, copying or any other distribution of this material is strictly prohibited. For further information call: 800-211-2769

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Vol. 5 (Issue 55)

March 2007

Tr e a t m e n t

Guidelines

from The Medical Letter®

Published by The Medical Letter, Inc. 1000 Main Street New Rochelle, N.Y. 10801 www.medicalletter.org

Tables First-Line Drugs Continuation Therapy Second-Line Drugs Combination Drugs

Page 16 Page 17 Page 18 Page 18

Drugs for Tuberculosis

Even though the incidence continues to decline, tuber- culosis (TB) is still a problem in the United States. Treatment of TB can be divided into treatment of latent infection and treatment of active disease. A table listing the first-line drugs used for treatment of TB with their doses and adverse effects can be found on page 16. Other guidelines with more detailed management rec- ommendations are available. 1 2,3

DIRECTLY OBSERVED THERAPY

LATENT TB INFECTION

The risk of patients with latent TB infection develop- ing active TB disease is extremely high in those who are co-infected with HIV or are receiving immuno- suppressive therapy. It is also high in children, in close contacts of patients with recent pulmonary TB, in pre- viously untreated patients with radiographic evidence of prior TB, during the first 2 years after development of a positive tuberculin test, and in immigrants from countries with a high incidence of TB. 6,7

Poor adherence to TB therapy is the most common cause of treatment failure and is associated with emer- gence of drug resistance. Medical Letter consultants recommend that almost all patients, including those with disease due to susceptible strains, take drugs for active TB disease under direct observation. Compared to self-administered regimens, directly observed ther- apy (DOT) has been shown to decrease drug resist- ance, relapse and mortality rates, and to improve cure rates.4,5 Due to the complexity and duration of TB treatment regimens, DOT is particularly important for treatment of patients with drug-resistant infections and for those on intermittent regimens because these are more susceptible to failure. Patients with latent infec- tion who are at high risk for developing active TB or are taking an intermittent regimen should also be con- sidered for DOT. DOT services are available through most local and state health departments.

The risk of serious disease, including miliary TB and tuberculous meningitis, is highest in infants, the eld- erly, and in patients with HIV infection or other caus- es of severe immunosuppression. Recent reports also indicate high risk for development of active TB dis- ease in persons with latent TB infection who are treat- ed with the TNF-alpha inhibitors infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira) for rheumatoid arthritis or some other con- dition. These reports include cases of extrapulmonary and disseminated disease, and deaths. Before begin- ning therapy with these drugs, testing for latent TB infection is recommended. 8,9

Diagnosis – The tuberculin skin test (purified protein derivative, PPD) has been in clinical use for over a century. Recently, interferon-gamma release assays

EDITOR: Mark Abramowicz, M.D. DEPUTY EDITOR: Gianna Zuccotti, M.D., M.P.H., Weill Medical College of Cornell University EDITOR, DRUG INFORMATION: Jean-Marie Pflomm, Pharm.D., CONTRIBUTING EDITOR, DRUG INFORMATION: Nina H. Cheigh, Pharm.D. ADVISORY BOARD: Jules Hirsch, M.D., Rockefeller University; James D. Kenney, M.D., Yale University School of Medicine; Richard B. Kim, M.D., University of Western Ontario; Gerald L. Mandell, M.D., University of Virginia School of Medicine; Hans Meinertz, M.D., University Hospital, Copenhagen; Dan M. Roden, M.D., Vanderbilt University School of Medicine; F. Estelle R. Simons, M.D., University of Manitoba; Neal H. Steigbigel, M.D., New York University School of Medicine EDITORIAL FELLOWS: Vanessa K. Dalton, M.D., M.P.H., University of Michigan Medical School; Eric J. Epstein, M.D., Albert Einstein College of Medicine DRUG INTERACTIONS FELLOW: Emily Ung, BScPhm, Children’s Hospital of Western Ontario SENIOR ASSOCIATE EDITORS: Donna Goodstein, Amy Faucard ASSISTANT EDITORS: Cynthia Macapagal Covey, Tracy Shields MANAGING EDITOR: Susie Wong PRODUCTION COORDINATOR: Cheryl Brown VP FINANCE & OPERATIONS: Yosef Wissner-Levy

Copyright 2007. The Medical Letter, Inc. (ISSN 1541-2792)

Federal copyright law prohibits unauthorized reproduction by any means and imposes severe fines.

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