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Side effects associated with anti-TB drugs and their prevention and management

Important general instructions

  • Ensure that patient completes full course of anti-TB therapy
  • Side effects of anti-TB drugs can be an important cause of patient stopping medication, especially with second line drugs
  • Prevention and early detection of side effects are needed
  • Alcohol, smoking and use of illicit drugs increase side effects
  • Relevant history, clinical examination and lab tests are important to evaluate risk factors and diagnosis of side effects at an early stage
  • For contraception, ask patient to seek advice from family planning center as oral contraceptives are less effective with some anti-TB drugs
  • Educate, counsel and reassure patients for self-limiting side effects
  • Side effects and serious side effects requiring immediate action —- refer patients to Medical officer
  • Report serious side effects to PvPI center (Procedure for reporting: Call your nearby PvPI center and provide complete information about side effect. ; Contact no: National toll free number: 18001803024)
  • Advice nutritious diet to TB patients
  • Advice patients about respiratory hygiene and provide information on preventing spread of TB (Cover nose and mouth with facemask, tissue paper)

Some common and rare side effects of anti-TB drugs

Common (Seen in 1-10% patients) Rare (Seen in less than 1% patients)
Nausea, Vomiting, Gastritis,Hepatitis,Hypersensitivity reactions,Cutaneous reactions Flu like syndrome, Peripheral neuropathy, Ocular toxicity, Dysglycemia,Gynaecomastia, Hypothyroidism, Joint related side effects,Tendinopathy and tendinitis, Myelosuppression, Anaemia, Thrombocytopenia,Psychosis, Seizures, Prolongation of QT interval

Symptoms, causative drugs and action to be taken by Health worker

Symptoms Which drugs cause Action by Health Workers
Upper abdominal pain – Frequent All oral anti-TB drugs Indicates gastritis. Advise patients to increase fluid intake. Patients should not take antacids/acid lowering agents together with first line anti-TB drugs as it reduces the absorption of drugs. Refer to Medical Officer.
Nausea, vomiting All oral anti-TB drugs Reassure patient. Advice patient to take drugs embedded in a banana. Give drugs with less water and over a longer period of time (e.g. 20 minutes). However, later in the day, patients should take sufficient water. If above measures fail, refer to Medical Officer.
Nausea, vomiting with yellowness of skin and dark colour urine Mainly by Pyrazinamide, Rifampicin and Isoniazid Indicates Liver toxicity. Refer to Medical officer urgently
Loose motions >4 times, liquid stools Mainly by PAS, Ethionamide, Isoniazid, Rifampicin, Ofloxacin, Levofloxacin, Moxifloxacin Counsel patients on food and personal hygiene. Advice 200 ml Oral rehydration solution (ORS) after every loose stool to maintain hydration. Refer to Medical officer.
Loose motions associated with dryness of skin and mouth decreased urination, tiredness and sunken eyes Same as above Indicates Dehydration (Serious) Refer to Medical officer urgently
Itching / Rashes Mainly by Ethambutol,Rifampicin,Streptomycin Reassure patient. If rash persists, refer to Medical Officer
Itching / Rashes involving very large body area or present in mouth, nose associated with swelling and fever Mainly by Ethambutol,Rifampicin Streptomycin Indicates systemic involvement (Serious) Refer to Medical officer urgently
Tingling /burning /numbness in hands and feet Mainly Isoniazid, Cycloserine Check that patientis taking Pyridoxine. Refer to Medical officer.
Pain in Joints Mainly Pyrazinamide Paracetamol can be given if only 1-2.joints are involved. Reassure patient that it is a self-limiting condition. If > 2 joints are involved or pain is not relieved, refer to Medical officer.
Impaired vision: Pain, Blurring of vision, Disturbance in color vision Mainly Ethambutol Indicates Eye toxicity.Refer to Medical officer urgently
Flu-like syndrome: Chills, dry cough, shortness of breath, loss of appetite, body ache, malaise Which drugs cause Mainly Rifampicin Reassure patient. If not controlled, refer patient to Medical Officer for evaluation.
Swelling of face or legs, less or no urine Amikacin, Kanamycin, Capreomycin, Streptomyin Indicates Kidney toxicity.Refer to Medical officer urgently
Seeing abnormal things, change of thoughts, suicidal thoughts Mainly Cycloserine Indicates Psychiatric disturbances.Refer to Medical officer urgently
Tiredness, lethargy, headache,giddiness, pale look, palpitations Mainly Linezolid, Isoniazid, Rifampicin, Pyrazinamide, Ofloxacin, Levofloxacin,Moxifloxacin Indicates Anemia. Patients can be advised rest in DOTS center post-dosing to avoid giddiness. Advice patients on nutritionRefer to Medical Officer for evaluation.
Ringing in ears, Loss of hearing, dizziness and loss of balance leading to recurrent fall Mainly Streptomycin, Amikacin, Kanamycin, Capreomycin Indicates Ear toxicity.Refer to Medical officer urgently
Slowness of activities, swelling of face, swelling in neck, disproportionate weight gain Mainly PAS and Ethionamide Indicates Thyroid involvement.Refer to Medical officer urgently
Pain and swelling in muscles and Tendons, difficulty in movement Ofloxacin, Levofloxacin and Moxifloxacin Indicates Tendonitis.Refer to Medical officer urgently
Seizure: Convulsion Isoniazid, Cycloserine, Ofloxacin, Levofloxacin, Moxifloxacin Refer to Medical officer urgently
Orange and reddish color of urine sweat, phlegm (sputum), saliva or tears may be noticed. As this is quite common with rifampicin, reassure patients.

Source: ICMR book on Prevention and management of adverse reactions associated with Anti TB drugs



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