Treatment of TB a pharmacy perspective

Treatment of TB a pharmacy perspective Colm McDonald, Antimicrobial Stewardship Pharmacist (Acting) National TB Conference, St. James s Hospital 6 th May 2011

Overview of presentation Role of the pharmacist in the TB service Case study No. 1; Treatment of pansensitive TB Case study No. 2; Treatment of MDR TB Treatment regimens for Latent TB Infection Access to TB medication nationally Questions References provided at appropriate points throughout the presentation. Not included in this presentation; TB and HIV as this is an area covered by specialist HIV pharmacists at St. James s Hospital

Role of the pharmacist in the management of TB *It is recommended that a pharmacist is a member of the clinical team and attends the clinics, where they have an important role to play in: 1) dispensing of TB medications to patients and maintaining dispensing records 2) providing appropriate written and verbal information to patients to enable them to understand and comply with their medication 3) promoting and monitoring patient compliance with their medication regime * Reference; Guidelines on the Prevention and Control of TB in Ireland, National TB Advisory Committee, April 2010

Role of the pharmacist in the management of TB 4) screening for potential drug interactions, monitoring adverse drug reactions and advising on their management, particularly for patients with MDR-TB and HIV-TB coinfection 5) maintaining links with community and hospital pharmacy services where appropriate and 6) Participating in clinical audit

Case Study 1; treatment of pansensitive TB (1 st Clinic visit)!"#$%! &'( ) *+,, -./!-0!1%!+ /$!+

Case Study 1; treatment of pansensitive TB main references 1. Guidelines on the Prevention and Control of TB in Ireland, National TB Advisory Committee, April 2010 (particulary regarding duration of therapy in pansensitive TB) 2. American Thoracic Society, Centers for Disease Control and Prevention, Infectious Disease Society of America. Treatment of tuberculosis. Am J Respir Crit Care Med 2003; 167:603-662 3. NICE Clinical Guideline CG117 on clinical diagnosis and management of TB, March 2011 (partial update of CG33 March 2006, includes new!( 2) 4. BTS Chemotherapy and management of TB in the UK, 1998. (now officially superceded by NICE CG117, but has some useful additional information)

Case Study 1; treatment of pansensitive TB (1 st Clinic visit)! 3 4, %43 5 %! 2)3 5 % 3.

Case Study 1; treatment of pansensitive TB (1 st Clinic visit) ) %! '4!6) '!7!!!. 84 4

Case Study 1; treatment of pansensitive TB (2 nd and subsequent visits) 94)3 65 %!( :3! %; ; < 8!4

Case Study 1; treatment of pansensitive TB duration of therapy* 2,, 3 %33 3, 84!5 % * Reference; Guidelines on the Prevention and Control of TB in Ireland, National TB Advisory Committee, April 2010

Case Study 1; adverse event elevated LFTs <,, 4.!( ( 3%4 1!7 : 3!

Case Study 1; adverse event elevated LFTs (04&(9 &(9 &(9),,.!!; =!! 3(, 3,

Multi Drug Resistant (MDR) TB Isoniazid and Rifampicin are the most important 1 st line anti-tb drugs BUT; no new 1 st line drugs in the past 40 years Sporadic ingestion, monotherapy, inadequate doses, malabsorption of medication, can lead to susceptible strains of M.tb becoming resistant to drugs (perhaps within one month)

Case Study 2 Treatment of MDR TB.8!:8< ), 8+ 8 8!!),/!+ '-!+ %-0!1%!2> :44?$$!+ 0$$! 8+ /0$!10$$! +

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Case Study 2 MDR TB Treatment Regimen ( )!3%*! 3.+,! ( -%*!?5*!3 3.+6!) % (.2?5*!!*! 3:8<6 4.6!,(,41 2:E!6,

Case Study 2 MDR TB Treatment Regimen - duration 2.7?*! 37 -/6-#

Case Study 2 MDR TB Treatment Regimen common adverse reactions %)!4 4 % ) 4/0!+.!., 8

Case Study 2 MDR TB Treatment Regimen other adverse reactions )%, % %!64 :44)%F! 4 <%4 3, <!=3

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Treatment of Latent TB Infection - references 1. Guidelines on the Prevention and Control of TB in Ireland, National TB Advisory Committee, April 2010 2. TNF-alpha antagonists and TB, Kavanagh and Gilmartin, HPSC 2007 3. NICE Clinical Guideline CG117 on clinical diagnosis and management of TB, March 2011 4. BTS recommendations for assessing risk and managing M.Tb infection and disease in patients due to start anti- TNF-alpha treatment, Thorax 2005; 60: 800-805

Access to TB medications -K?LE5!.. E E.!.A B!5! 3 E'

Access to TB medications (..HME5 6 E'. E'81:6() #( 3 E' =. 3 ;

Thank you for your attention F;