Management of the Active TB Patient at Risk of Hepatotoxicity

Draw baseline labs for Total Bilirubin, Aspartate Amino Transferase, Alanine Aminotransferase, Alkaline Phosphatase and HIV.

If normal, start INH, Rifampin, Pyrazinamide and Ethambutol. Repeat T. Bili and Liver Function Tests if clinical assessment identifies need or signs and symptoms of hepatitis develop.

If Total Bilirubin, Aspartate Amino Transferase and Alanine Aminotransferase are stable, then monitor Total Bilirubin and Liver Function Tests monthly.

If baseline labs for Total Bilirubin, Aspartate Amino Transferase, Alanine Aminotransferase, Alkaline Phosphatase and HIV are abnormal, then eliminate alcohol or other hepatotoxic agents. Repeat Liver Function Tests in 7 to 10 days.

If Liver Function Tests are less than 3 times upper limit normal then start INH, Rifampin, Pyrazinamide, Ethambutol and repeat Total Bilirubin and Liver Function Tests every 2 weeks until stable for 1 month. Draw Liver Function Tests and if stable or improved, the patient is clinically well. If patient develops clinical toxicity or elevated Total Bilirubin or Liver Function Tests, hold TB medication then do Total Bilirubin and Liver Function Tests at least weekly. When Aspartate Amino Transferase, Alanine Aminotransferase is less than 2 times normal start Rifampin, Ethambutol (After hepatotoxicity develops medications should be daily).

Draw Total Bilirubin and Liver Function Tests 2 times per week. When Liver Function Tests are stable for 1 week add INH. Check Total Bilirubin and Liver Function Tests 2 times a week. If Total Bilirubin and Liver Function Tests are stable for 2 weeks then keep checking Total Bilirubin and Liver Function Tests monthly. If Liver Function Tests and or Total Bilirubin increase then hold TB medication and check Total Bilirubin and Liver Function Tests until they are less than 2 times normal and add Rifampin, Ethambutol, Fluoroquinolone. After hepatotoxicity develops, medications should be daily. Seek medical consultation. Check Total Bilirubin and Liver Function Tests 2 times a week, if stable for 2 weeks check Total Bilirubin and Liver Function Tests monthly.

If Total Bilirubin and Liver Function Tests showed that Aspartate Amino Transferase, Alanine Aminotransferase and or Total Bilirubin further increased, stop Rifampin and Ethambutol. When Aspartate Amino Transferase and Alanine Aminotransferase are less than 2 times normal, start INH, Ethambutol, Fluoroquinolone, IA injectable agent (streptomycin, amikacin, capreomycin). After hepatotoxicity develops medications should be daily. Seek medical consultation.

Check Total Bilirubin and Liver Function Tests 2 times a week. If stable for 2 weeks, check on a monthly basis. If Liver Function Tests and or Total Bilirubin increase, Begin Fluoroquinolone, Ethambutol, IA injectable agent (streptomycin, amikacin, capreomycin). After hepatotoxicity develops medications should be daily. Seek medical consultation.

If baseline labs for Total Bilirubin, Aspartate Amino Transferase, Alanine Aminotransferase, Alkaline Phosphatase and HIV are abnormal and Liver Function Tests are greater than 3 times the upper limit normal and patient is asymptomatic, begin 2 hepatotoxic drugs (usually INH, Rifampin, Ethambutol). After hepatotoxicity develops medications should be daily. Repeat Total Bilirubin and Liver Function Tests at least every 2 weeks. If Total Bilirubin and Liver Function Tests are stable for 1 month then check Total Bilirubin and Liver Function Tests monthly. If the patient is Symptomatic begin one hepatotoxic drug (usually Rifampin, Ethambutol, Fluoroquinolone). After hepatotoxicity develops medications should be daily. Seek medical consultation.

Draw Total Bilirubin and Liver Function Tests at least weekly, if Liver Function Tests are stable for 2 weeks then check Liver Function Tests on a monthly basis. If Total Bilirubin and or Liver Function Tests increase then hold treatment and begin Fluoroquinolone, Ethambutol, IA injectable agent (streptomycin, amikacin, capreomycin). After hepatotoxicity develops medications should be daily. Seek medical consultation. If Liver Function Tests improve Consider addition of INH to Rifampin, Ethambutol and Fluoroquinolone. After hepatotoxicity develops medications should be daily. Check Total Bilirubin and Liver Function Tests weekly and if Total Bilirubin and Liver Function Tests are stable for 1 month, check monthly. If clinical toxicity or Aspartate Amino Transferase, Alanine Aminotransferase, or Total Bilirubin increase; hold medications and check Total Bilirubin and Liver Function Tests at lease weekly. Once Total Bilirubin, Aspartate Amino Transferase, Alanine Aminotransferase are less than 2 times normal or return to baseline, then start Rifampin, Ethambutol, Fluoroquinolone. After hepatotoxicity develops medications should be daily. Seek medical consultation. Check Total Bilirubin and Liver Function Tests and if stable for 2 weeks, check monthly.

If Liver Function Tests are greater than 5 times the upper limit normal after eliminating alcohol or other hepatotoxic agents and patient is asymptomatic, begin one hepatotoxic drug (usually Rifampin, Ethambutol, Fluoroquinolone). After hepatotoxicity develops medications should be daily. Seek medical consultation.

Draw Total Bilirubin and Liver Function Tests at least weekly, if Liver Function Tests are stable for 2 weeks then check Liver Function Tests on a monthly basis. If Total Bilirubin and or Liver Function Tests increase then hold treatment and begin Fluoroquinolone, Ethambutol, IA injectable agent (streptomycin, amikacin, capreomycin). After hepatotoxicity develops medications should be daily. Seek medical consultation. If Liver Function Tests improve Consider addition of INH to Rifampin, Ethambutol and Fluoroquinolone. After hepatotoxicity develops medications should be daily. Check Total Bilirubin and Liver Function Tests weekly and if Total Bilirubin and Liver Function Tests are stable for 1 month, check monthly. If clinical toxicity or Aspartate Amino Transferase, Alanine Aminotransferase, or Total Bilirubin increase; hold medications and check Total Bilirubin and Liver Function Tests at lease weekly. Once Total Bilirubin, Aspartate Amino Transferase, Alanine Aminotransferase are less than 2 times normal or return to baseline, then start Rifampin, Ethambutol, Fluoroquinolone. After hepatotoxicity develops medications should be daily. Seek medical consultation. Check Total Bilirubin and Liver Function Tests and if stable for 2 weeks, check monthly. If patient is symptomatic then begin Fluoroquinolone, Ethambutol, IA injectable agent (streptomycin, amikacin, capreomycin). After hepatotoxicity develops medications should be daily. Seek medical consultation.