Initial Treatment for Newly Diagnosed TB with Deranged LFTs

Assessing Liver Dysfunction and Initial Treatment

For a newly diagnosed TB patient with deranged liver function tests (LFTs) and AST/ALT less than 2 times normal, the American Thoracic Society recommends starting standard four-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) and repeating LFTs at 2 weeks 1, 2
For a newly diagnosed TB patient with deranged LFTs and AST/ALT 2-5 times normal, the American Thoracic Society recommends starting standard four-drug therapy with weekly LFT monitoring for two weeks, then biweekly until normal 1, 2, 3
For a newly diagnosed TB patient with deranged LFTs and AST/ALT 5 times normal or higher, or any bilirubin elevation, the Centers for Disease Control and Prevention recommends not starting rifampicin, isoniazid, or pyrazinamide 1, 2, 3, 4

The Infectious Diseases Society of America recommends starting the standard four-drug regimen (isoniazid, rifampicin, pyrazinamide, and ethambutol) for mild-to-moderate elevation (AST/ALT <5x Normal, Normal Bilirubin) 5, 6
The World Health Organization recommends using streptomycin and ethambutol as initial therapy until liver function normalizes for severe elevation (AST/ALT ≥5x Normal or Any Bilirubin Rise) 1, 2, 3

The American College of Chest Physicians recommends weekly LFTs for 2 weeks, then biweekly for the first 2 months, and educating the patient to stop medications immediately if fever, malaise, vomiting, jaundice, or abdominal pain develop 1, 2, 3
The European Respiratory Society recommends checking renal function before using streptomycin or ethambutol, as both require dose adjustment in renal impairment 2, 7, 4

The American Association for the Study of Liver Diseases recommends more intensive monitoring for patients with pre-existing chronic liver disease, advanced age, alcohol consumption, diabetes mellitus, chronic kidney disease, or poor nutritional status 1, 2, 3, 4