IM27.13-18 | Tuberculosis Treatment and National Program — Summary & Reflection

KEY TAKEAWAYS

TB treatment under NTEP is built on four pillars: correct categorisation, standardised regimens, adherence infrastructure, and programme accountability.

Drug-sensitive TB regimen: 2HRZE + 4HRE, daily, weight-band FDC dosing (<55 kg: 3 tabs; 55–69 kg: 4 tabs; ≥70 kg: 5 tabs). No thrice-weekly regimen. CNS/miliary TB: 12 months total + steroids. Pyridoxine always co-prescribed. Sputum check at month 2; if positive, CBNAAT for rifampicin resistance.

Pharmacology key points:
- Isoniazid: mycolic acid synthesis inhibitor; peripheral neuropathy (prevent with pyridoxine); DILI; CYP2C19 inhibitor
- Rifampicin: RNA polymerase inhibitor; sterilising agent; orange urine (harmless); potent CYP3A4 inducer (OCP failure, nevirapine failure — switch to efavirenz in HIV)
- Pyrazinamide: active in acidic macrophage environment; hepatotoxicity; hyperuricaemia; arthralgia
- Ethambutol: arabinosyl transferase inhibitor; optic neuritis (monthly vision/colour check)

DILI management: ALT >5× ULN → stop ALL four drugs → monitor LFTs → reintroduce sequentially (R first, then H, then Z)

DR-TB: MDR = resistant to H + R. Triggered by: prior treatment, contact with MDR case, month-5 failure. Diagnosis: CBNAAT + LPA + DST. Regimen: BLLfxCfzCs or BPaL (XDR-TB); 18–20 months (6 months for BPaL).

Contact chemoprophylaxis: Children <5 years, household contacts, no active TB → isoniazid 10 mg/kg/day × 6 months. All PLHIV → 6H (IPT) regardless of contact status.

Ni-kshay notification: Mandatory within 24 hours; triggers Ni-kshay Poshan Yojana (₹500/month nutritional support).

Cure criteria (DS-TB): Bacteriologically confirmed case completing treatment with negative sputum smear at end of intensive phase AND at end of treatment.

REFLECT

Reflect on Ravi's story from the opening hook — a labourer who developed hepatotoxicity from his ATT in week three. The standard response would be to check liver enzymes and reintroduce drugs sequentially. But Ravi's experience also raises a deeper question: who is responsible for ensuring he knows that dark urine and jaundice are warning signs to report immediately? The pharmacological knowledge you have learned in this module is only useful if it is communicated to the patient in a form they can act on. Think about how you would explain, in accessible language and in Tamil or Telugu rather than English, the following: why he must take all tablets every day without fail; why his urine will turn orange; what symptoms should prompt an emergency visit; and why his treatment supervisor needs to watch him take his tablets. TB treatment is a partnership between physician, programme, and patient. As you enter clinical practice, consider what barriers — language, literacy, stigma, working hours, distance — might separate a patient like Ravi from treatment completion, and what NTEP mechanisms exist to address each one.