Treatment of Tuberculosis in Patients with Hepatitis
Initial Assessment and Risk Stratification
- The American Thoracic Society and the Infectious Diseases Society of America recommend baseline hepatitis B and C screening for patients with a history of injection drug use, birth in Asia or Africa, or HIV infection, as well as baseline liver function tests including ALT and total bilirubin, to assess hepatic reserve and determine severity of underlying liver disease 1, 2
- Abnormal baseline aminotransferases alone are an independent risk factor for drug-induced liver injury (DILI), and the likelihood of hepatotoxicity increases with advanced liver disease, liver transplant, or hepatitis C infection 1, 2
Treatment Algorithm Based on Hepatic Disease Severity
- For patients with mild hepatic disease or ALT ≤3x Upper Limit of Normal, the standard regimen with PZA omitted is recommended, consisting of INH, RIF, and EMB for 2 months, followed by 7 months of INH and RIF, as suggested by the Centers for Disease Control and Prevention 1, 2
- For patients with advanced liver disease or ALT >3x Upper Limit of Normal, consider regimens with fewer hepatotoxic agents, such as INH, RIF, and EMB for 2 months, followed by 7 months of INH and RIF, or alternative regimens with a fluoroquinolone, injectable, or cycloserine for 12-18 months, as recommended by the World Health Organization 1, 2
Monitoring Protocol
- For patients with isolated hyperbilirubinemia, weekly monitoring for the first two weeks, then biweekly for the first two months is recommended, as advised by the European Respiratory Society 3
Discontinuation Criteria
- Stop all antitubercular therapy immediately if aminotransferases are >5 times upper limit of normal in asymptomatic patients or if serum bilirubin concentration is above normal range, as recommended by the American Association for the Study of Liver Diseases 3
Critical Pitfalls to Avoid
- Never assume hepatotoxic drugs cannot be used - The crucial efficacy of INH and particularly RIF warrant their use even with preexisting liver disease, as stated by the National Institutes of Health 1, 2
- Do not use pyrazinamide in patients with baseline liver abnormalities - PZA has the highest hepatotoxic potential and poorest prognosis when causing hepatitis, as warned by the Food and Drug Administration 1, 2
- Always obtain drug susceptibility testing to fluoroquinolones and injectables if considering their use in modified regimens, as recommended by the Centers for Disease Control and Prevention 1, 2