Download Results of the TB treatment

Results of the TB treatment
95%
Paranemine
Surm
Krooniline kulg
69%
50%
31% 33%
25%
25%
36%
24%
7%
2%
TB ilma ravita
2%
TB hea ravikorraldus
MDR TB ravi
Drug-sensitive cases -- at least 85% should be cured
MDRTB - over 70% cured
XDR-TB- 30-40 % should be cured
TB/HIV coinfection- results are on lower level
XDR-TB ravi
TREATMENT REGIMENS
l
The preferred regimen for active drug-sensitive TB disease is
minimum of 6 months
First 2 months (the intensive phase of treatment),
rifampicin, isoniazid, pyrazinamide, ethambutol
followed by isoniazid and rifampicin for 4 months (the continuation
phase of treatment)
Relaps - 8 months
3 months
5 months
- 5 drugs
- 3 drugs
Treatment efficacy and progress are usually monitored with repeat
sputum smears, cultures and chest X-rays.
TB treatment is free for all persons in Estonia, despite of living
place and having health insurance or not
Drug dosing freaquency
•
The optimal dosing frequency is daily throughout the course of therapy
•
Dosing of anti-TB drugs is based on the weight of the patient.
•
Monthly monitoring of patient body weight is important, medication dose should be
adjusted.
•
Once-daily dosing is mandatory for anti-TB drugs from Group 1, 2, and 3, as this is
thought to improve the peak-dependent killing.
•
Twice-daily dosing is an excellent strategy to reduce adverse effects of Group 4 drugs.
•
Many patients can tolerate a full dose of ethionamide and cycloserine once daily
Traditionally they have been given twice daily to reduce adverse effects.
•
Once-daily dosing is allowed for Group 4 drugs. There are no studies comparing
once-daily to twice-daily dosing for Group 4 drugs in terms of efficacy.
The common adverse events are
mild increases in the level of liver enzymes, skin rash, gastrointestinal
intolerance, neuropathy and arthralgia and can be managed
symptomatically without discontinuation of the offending drugs.
Serious adverse events are severe hepatitis, immune
thrombocytopaenia, agranulocytosis, haemolysis, renal failure, optic
neuritis and ototoxicity.
prolonged therapy undermines patient compliance. As a result,
supportive measures are necessary to ensure optimal adherence, as lack
of treatment completion contributes to treatment failure, relapse and the
emergence of drug resistance.
Symptom-based approach to managing side-effects of anti-TB drugs
The action of anti-tuberculosis drugs
1. Rapidly multiplying→ INH
2. Slowly multiplying→ PZ
3. Intermittent growth→ RIF
Bactericidal activity
H>>SM>R>E
Z>>R>H
R>>H
Total duration of MDR-TB treatment
 Treatment should continue for a minimum of
20 months and at least 18 months after
the patient becomes culture-negative
 Chronic patients with extensive pulmonary disease may require
MDR-TB treatment for 24 months or longer.
 A 9–12-month regimen (conditional WHO recommendation with
very-low-quality evidence) might be used in selected patients, in
appropriate settings, taking into account previous treatment and local
resistance profiles
Medicines recommended for the treatment of
rifampicin-resistant and multidrug-resistant TB1
Directly Observed Treatment, DOT
The most common adherence monitoring approach is directly observed
therapy (DOT)
•
•
Every dose of treatment is directly supervised by a health
professional, although the effectiveness of this measure is
controversial.
Although DOT continues to be valuable in many settings, various
alternative methods are now being tried out to improve adherence
o mobile phone reminders,
o smart pill boxes,
o video DOT and the use of call centres to follow-up with patients.
•
Regardless of the method, it is crucial to use a team-based, patientcentric approach that incorporates education, counselling and patient
empowerment.
Surgical treatment
It remains one of the treatment options for TB.
 Surgery has been employed in treating TB patients since before the
advent of chemotherapy


Segmentectomie, lobectomie, atypical resection, pulmonectomy

Partial lung resection for patients with MDR-TB is only to be
considered under conditions of good surgical
S

Facilities, trained and experienced surgeons and with careful
selection of candidates.
Treatment with TB drugs after hte surgery
Drug sensitive TB case : 4-6 months
MDR-TB: 9-12 months

Аgnessa 29 years
X-ray:10.01.2011 - before the surgery
TB treatment before the surgery- 1 year
After the surgery - 11 months
TB treatment. EPTB
 A 6 to 9-month regimen is recommended as initial therapy for all
forms of extrapulmonary tuberculosis unless the organisms are
known or strongly suspected to be resistant to the first-line drugs.
2 months of isoniazid, rifampicn, pyrazinamide, ethambutol,
4 -7 months of isoniazid and rifampin
 For patients with CNS tuberculosis, including meningitis,
at least nine to 12 months of therapy is recommended.
 Extended therapy also may be required for patients with
bone and joint tuberculosis,
delayed treatment response, or
drug resistance.
 Adjunctive corticosteroids may be useful in patients who have
tuberculous meningitis, tuberculous pericarditis, or miliary
tuberculosis with refractory hypoxemia.
Treatment success of all TB cases, EU/EEA, 2014
74.0% of all TB cases* had a successful treatment outcome after
12 months (range 0.0–92.8%)
Slovakia
Iceland
Sweden
Netherlands
Norway
Bulgaria
United Kingdom
Romania
Belgium
Slovenia
Latvia
Spain
Malta
Hungary
Portugal
Estonia
Austria
Czech Republic
Lithuania
Germany
Poland
Ireland
Denmark
Finland
Cyprus
Croatia
Luxembourg
EU/EEA
0
10
20
30
40
50
60
70
80
90
100
Treatment success (%)
Source: European Centre for Disease Prevention and Control.
TB surveillance and monitoring in Europe, 2016.
* Four EU/EEA Member States did not report treatment outcome data
16
Indicator 7: Treatment success rate new pulmonary
culture positive MDR TB cases*
Target: Treatment success of 70% for new pulmonary
culture-positive MDR TB cases
 Status 2014: Success rate in EU/EEA was 55.6% (range
0–100.0%), target met by 6 countries

17 European Centre for Disease Prevention and Control.
Source:
TB surveillance and monitoring in Europe, 2016.
* Luxembourg reported ‘zero’ cases; France, Greece, and Italy did not report
treatment outcome results.
Treatment outcomes in MDR TB notified in 2010-2012,
EU/EEA, 2014
Treatment success rates increased from 32% to 40% in the 2010,
2011 and 2012 cohorts
50
Percentage
40
MDR TB cohort 2010
30
MDR TB cohort 2011
MDR TB cohort 2012
20
10
0
Success
Died
Source: European Centre for Disease Prevention and Control.
TB surveillance and monitoring in Europe, 2016.
Failed
Defaulted or
unknown
Still on
treatment
18
Additional support
Since 2011 the NTP allocates additional finances for provision of
 voluntary treatment of Alcohol Use Disorders
 and/or drug abuse (including methadone substitution treatment,
naltrexone, disulfiram etc.)
 psycho-social counselling
 support together with TB treatment

These additional services are given by a team consisting of
social workers,
psychologist,
psychiatrist
and they belong to this department.
Treatment outcomes in MDR TB notified in 2012,
EU/EEA, 2014
The success rate was 40,3% (treatment started in 2012 )
< 40%
40 to 69.9%
≥ 70%
Not reporting
20 European Centre for Disease Prevention and Control.
Source:
TB surveillance and monitoring in Europe, 2016.
* Cyprus, Luxembourg, Malta and Slovenia reported zero MDR TB cases in 2012.
Nine Member States did not report treatment outcome data for MDR TB cases.