Monitoring the HIV-infected patient on antituberculous medications
- Timothy R Sterling, MD
Timothy R Sterling, MD
- Professor of Medicine
- Vanderbilt University School of Medicine
The approach to the treatment of tuberculosis (TB) in the HIV-infected patient is complex and needs to address the patient's requirement for antiretroviral therapy (ART), potential drug reactions, and complications related to the immune reconstitution inflammatory syndrome (IRIS). Follow-up should be designed to monitor both bacteriologic and clinical efficacy of the therapeutic regimen.
This topic will cover the appropriate follow-up of HIV-infected patients with TB including directly observed therapy, the clinical response to treatment, adverse events related to treatment, duration of treatment, and prognosis.
The clinical manifestations, diagnosis, and treatment of susceptible TB in the HIV-infected patient are discussed elsewhere (see "Epidemiology, clinical manifestations, and diagnosis of tuberculosis in HIV-infected patients" and "Treatment of pulmonary tuberculosis in HIV-infected adults" and "Treatment of latent tuberculosis infection in HIV-infected adults"). Treatment of multidrug-resistant tuberculosis in HIV-infected patients is discussed elsewhere (see "Diagnosis and treatment of extensively drug-resistant tuberculosis" and "Diagnosis, treatment, and prevention of drug-resistant tuberculosis").
DIRECTLY OBSERVED THERAPY
Directly observed therapy (DOT) is the most effective way to maximize adherence  and is recommended by most tuberculosis (TB) experts and the World Health Organization (WHO) for all TB patients [2-4]. In some programs, patients are observed taking their medications Monday through Friday and are given their doses to take over the weekend for greater patient convenience.
Although DOT programs require a significant commitment of resources, they are very effective in decreasing rates of primary and acquired drug resistance [1,5]. In developing countries where TB and HIV are endemic, DOT is associated with lower TB relapse rates and a higher percentage of patients who complete their full duration of TB therapy [6,7].
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- DIRECTLY OBSERVED THERAPY
- RESPONSE TO THERAPY
- Clinical response
- Bacteriologic efficacy
- CLINICAL DETERIORATION
- Predictors of relapse
- Intercurrent opportunistic infection
- Immune reconstitution inflammatory syndrome
- DRUG-RELATED SIDE EFFECTS
- Peripheral neuropathy
- Visual abnormalities
- - Ethambutol
- - Rifabutin
- - CMV retinitis
- THERAPEUTIC DRUG MONITORING
- DURATION OF THERAPY
- Standard duration
- When to prolong therapy
- Adjuvant corticosteroids
- Clinical outcomes
- Impact of ART on mortality
- Impact of cotrimoxazole prophylaxis on mortality
- SUMMARY AND RECOMMENDATIONS