Objectives of this module

DOT means the health worker has to: • ensure that the drugs are swallowed. • know immediately if treatment is interrupted and allow the health facility to take action, such as tracing the interrupting patient and encouraging the patient to resume treatment. • establish a supportive relationship with the patient. A good relationship enables the patient to discuss questions or fears about the disease and treatment, thereby allowing the health worker to monitor and supervise the patient adequately.

The first-line drugs used to treat drug-susceptible TB are very efficacious and tolerable, whereas, second-line drugs (SLD) used to treat MDR-TB are less efficacious and cause more adverse drug reactions (ADR). The ADRs occur mainly during the first few months of treatment. As some ADRs are self-limiting and resolve after a short time, others can be treated with drugs according to the symptoms experienced by the patient. All ADRs must be managed or treated until the patient develops a tolerance for these effects or until the ADRs resolve by themselves. Reducing the drug dose may be an alternative and the withdrawal of the drug or its replacement should be taken as a last measure. The very serious ADRs are not too common and it is important to be aware that without adequate treatment, MDRTB mortality is very high. In cases in which there is resistance to multiple drugs and only a few drugs can be used, stopping any of these drugs because of severe ADRs, for example may result in treatment failure.

The effect of Category IV treatment on a patient with pulmonary TB must be monitored by follow-up sputum smear, culture and if necessary, DST. Negative sputum smears and cultures at specific times indicate good treatment progress, which encourages the patient to continue treatment and motivates the health worker responsible for supervising the treatment. Culture examinations are also required to determine whether the TB patient is cured, or failed.

Below is a summary list of the procedures to treat MDR-TB cases.

Initially: • Design the patient’s treatment regimen based on DST results and history of treatment. Present to the consilium for approval of regimen design. Inform the patient and family about MDR-TB and its treatment. Weigh the patient and prepare the patient’s Category IV Treatment Card.

Prepare the patient’s initial dose. Give the patient a brief orientation on the drugs that will be taken and the expected ADRs associated with each drug. Prepare the PMDT Patient’s Booklet.

On an ongoing basis: • Supervise and record drug intake daily until completion of treatment. • Monitor whether the patient has side-effects. • Continue to give the patient information and support for continuing treatment.

At specified intervals: • During the intensive phase, collect one sputum specimen monthly for follow-up smear and culture examination; in the continuation phase, collect one sputum specimen monthly for smear and every 2 months for culture. • Conduct a physical examination once a month and as needed. • Do blood chemistries (example, liver and renal function tests) every three months for patients 50 years and older and every six months for younger patients; and do chest x-ray every six months, or more often when necessary, record results and take necessary action.

Participants will be able to:

Determine appropriate treatment regimen using the DST results and patients’ history of drug use Prepare a patient’s Category IV Treatment Card, including specifying the treatment regimen and dose Administer supervised treatment and record it on the Category IV Treatment Card Recognize side-effects and what to do Determine when an MDR-TB patient is due for follow-up examination Interpret the results of follow-up exams and decide 4.4 – 4.6

on the appropriate course of action Determine treatment outcome

Refer to section:

1.1

1.7

2

3 4.1

5

Note: Some procedures are described in their appropriate places in the sequence of steps for treating MDR-TB cases, but more detail is provided in other modules:

Providing information about MDR-TB to the patient and the family is taught in Module D: Inform

Patients about MDR-TB. Dealing with problems, such as when a patient stops coming for treatment, is taught in Module E: Ensure Continuation of MDR-TB Treatment. Preparing patient’s drugs is taught in Module F: Manage Drugs and Supplies for MDR-TB.

If you need to look up an unfamiliar word, refer to the glossary at the end of Module A: Introduction. The flow chart on the next page summarizes the tasks and forms that will be discussed in this module.

FIGURE 1 . Flow chart for the treatment of MDR-TB patients

MDR-TB patient or seriously ill MDR-TB suspect

TC physician proposes drug regimen to Consilium

Consilium approves drug regimen

Enroll the MDR-TB patient at the Treatment Center (TC) • Contact patient for enrollment • Inform the patient on the enrollment procedures • Request baseline laboratory tests

Supervise the patient during the entire period of treatment • Directly observe each treatment • Continue providing information about TB

Monitor the patient for adverse drug reactions (ADRs) • Directly observe each treatment • Continue providing information about TB Monitor the progress of treatment by follow-up examinations: • Smears: monthly until treatment is completed • Cultures: monthly during the intensive phase and every two months during the continuation phase or whenever indicated • DST: every 4 months while culture-positive when resistance amplification is suspected • Chest x-ray: every 6 months • Blood chemistries: every 6 months for patients younger than 50 years; every 3 months for patients 50 years and older.

Implement treatment decisions

FORMS USED

Consiliumex

Kasunduan or Contract Enrollment Checklist Social Case Study Report Form (SCSRF) and Socioeconomic Classification Form Mycobacteriology Request Form Chest X-ray Request Form Blood Chemistry Request Form Category IV Register

Category IV Treatment Card

Progress Report Form

Consiliumex