Assessing and Managing the Risk of Liver Disease in the Treatment of Latent TB Infection.

Are baseline labs needed? Baseline labs should be drawn if patients are HIV infected,pregnant or post-partum (within 3 mo. of delivery), has a history of liver disease, regular alcohol use or taking hepatotoxic medications. Liver Function Tests should include serum Alanine Aminotransferase, Aspartate Amino Transferase, total bilirubin.

If baseline labs are not needed then start Isoniazid and educate the patient about clinical indicators of hepatotoxicity. Do monthly clinical assessments in person and draw Liver Function Tests if clinical assessment indicates need, for example if patient has clinical indicators of hepatotoxicity such as flue-like symptoms, abdominal pain, nausea or vomitting, jaundice, anorexia, dyspepsia, and fatigue.

If baseline labs are needed then check baseline Liver Function Tests. If Liver Function Tests are within normal limits, if significant risk of underlying liver disease then continue monthly monitoring of Liver Function Tests and then start Isoniazid and educate patient about clinical indicators of hepatotoxicity. Do monthly clinical assessments in person and check Liver Function Tests if clinical assessment indicates need, for example if patient has clinical indicators of hepatotoxicity such as flue-like symptoms, abdominal pain, nausea or vomitting, jaundice, anorexia, dyspepsia, and fatigue.

If Liver Function Tests are abnormal, less than three times the upper limit of normal, and the patient is well. Start Isoniazid and repeat Liver Function Tests every 2 weeks for one month and then monthly.

If Liver Function Tests are within normal limits for two months, continue Isoniazid and monthly clinical assessment. check Liver Function Tests if clinical assessment indicates need, for example if patient has clinical indicators of hepatotoxicity such as flue-like symptoms, abdominal pain, nausea or vomitting, jaundice, anorexia, dyspepsia, and fatigue.

If Liver Function Tests are abnormal, less than 3 times the normal and patient is well. Continue Isoniazid and check Liver Function Tests monthly. If symptoms of hepatotoxicity or Liver Function Tests increase further, stop Isoniazid! Consider treatment with daily rifampin for 4 months especially if at high risk for progression to active disease. Draw a CBC with platelet count prior to initiation of rifampin. Adverse effects of treating LTBI serious enough to require hospital admission or death should be reported to the CDC through local public health authorities or by calling 404-639-8401. If Liver Function Tests stable, complete regimen.

If Liver Function Tests are greather than 3 times the normal and symtoms of hepatotoxicity, stop Isoniazid! Consider treatment with daily rifampin for 4 months especially if at high risk for progression to active disease. Draw a CBC with platelet count prior to initiation of rifampin. Adverse effects of treating LTBI serious enough to require hospital admission or death should be reported to the CDC through local public health authorities or by calling 404-639-8401. Educate patient on signs and symptoms of TB and need to report them to the provider.

If Liver Function Tests are greater than 3 times the normal, do not start until clinical assessment is performed by a physician.

If Liver Function Tests less than 5 times the upper limit, and the patient is well but at a high risk for progression to active TB. Consider treatment with daily rifampin for 4 months especially if at high risk for progression to active disease. Draw a CBC with platelet count prior to initiation of rifampin. Adverse effects of treating LTBI serious enough to require hospital admission or death should be reported to the CDC through local public health authorities or by calling 404-639-8401. Give 600mgs. daily for 4 months.

Check Liver Function Tests every 2 weeks for 2 months, If symptoms of hepatotoxicity or Liver Function Tests increase further stop the regimen. If the patient remains asymptomatic and Liver Function Tests are stable, check Liver Function Tests monthly.

If Liver Function Tests are greater than equal to 5 times the normal, then stop the regimen. Seek a medical consultation and educate patient on signs and symptoms of TB and need to report them
to provider.

Produced by the Heartland National TB Center. Consultation to healthcare providers at 1-800-TEX-LUNG, www.HeartlandNTBC.org
This product funded by the Centers for Disease Control and Prevention (CDC).