Special situations in drug-susceptible tuberculosis treatment — MSF Tuberculosis

What this guideline says

GMJ summary

This section of the MSF tuberculosis clinical guideline addresses treatment adaptations for drug-susceptible TB in five special populations: pregnant and breastfeeding women, women of childbearing age, malnourished patients, patients with diabetes, and those with renal insufficiency. The guidance provides specific dosing recommendations for vitamin supplementation and contraindications for certain regimens in pregnancy.

All conventional TB drugs except rifabutin can be used safely during pregnancy and breastfeeding, though vitamin B6 and K supplementation are required. Alternative regimens containing rifapentine, moxifloxacin or ethionamide cannot be used in pregnant or breastfeeding women. For malnourished children with severe acute malnutrition, a 6-month regimen is preferred over the 4-month regimen. In diabetes, closer glucose monitoring is essential as TB impairs glycaemic control, and ethambutol should be avoided in diabetic retinopathy. For renal insufficiency with creatinine clearance below 30 ml/minute, TB drug doses require adjustment.

The guidance emphasises the importance of nutritional support during the first two months of treatment for at-risk groups including children, pregnant and breastfeeding women, and older patients. Women of childbearing age require specific contraceptive counselling, as rifamycins reduce the effectiveness of oral and implantable contraceptives, necessitating use of intra-uterine devices or injectable progestogen-only methods.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Pregnant and breastfeeding women should receive pyridoxine 10 mg once daily orally throughout TB treatment; breast-fed infants should receive pyridoxine 5 mg once daily
2. Women in late pregnancy on rifampicin should receive phytomenadione 10 mg once daily orally for 2 weeks prior to expected delivery; neonates should receive phytomenadione 1 mg intramuscularly as a single dose at birth
3. Alternative regimens containing rifapentine, moxifloxacin and/or ethionamide cannot be used in pregnant and breastfeeding women with DS-TB
4. Women of childbearing age on TB treatment should use intra-uterine devices or progestogen-only injectable contraception, as rifamycins reduce effectiveness of implants and oral contraceptives
5. Children with severe acute malnutrition should receive a 6-month regimen rather than a 4-month regimen until more efficacy data become available
6. Avoid prescribing ethambutol in patients with pre-existing diabetic retinopathy
7. In renal insufficiency with creatinine clearance less than 30 ml/minute, doses of certain TB drugs require adjustment
8. Nutritional supplementation may be considered during the first 2 months of treatment for at-risk groups: children, pregnant and breastfeeding women, and older patients

From the guideline

Verbatim

“All TB drugs used in conventional regimens, except rifabutin, can be used during pregnancy and breastfeeding.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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