Most patient complete treatment uneventfully. However, some patients do have problems during treatment.
In a few patients, haemoptysis may continue during the early part of treatment.
The sight of blood alarms the patient and creates doubts in his mind about his treatment. Prompt treatment, an explanation and reassurance go a long way in gaining the confidence of the patient.
It is important to explain the symptoms of common side effects to the patient.
The patient should be asked to report when he develops these symptoms.
Reassure him when he has side effects and treat them promptly and adequately. A patient with a symptoms free treatment period is more likely to complete it.
Side effects are an important reason for interruption of treatment.
Haemoptysis
Haemoptysis can occur at anytime before, during and after completion of treatment. Although alarming to the patient, and sometimes to the doctor, its occurrence during treatment does not by itself indicate active disease or deterioration of clinical condition. Unless accompanied by reversal of sputum status to positive, its occurrence definitely does not warrant any change in the anti-TB regime.
Mild haemoptysis can be managed at home with reassurance, sedatives, cough suppressants like codeine or dextromethorphan, haemostatics and bed rest. Sometimes, haemoptysis is brough on by a recurrence of cough due to a superadded beacterial or viral respiratory infection.
In such a situation, an antibiotic, (Ciprofloxacin, ofloxacin, clarithromycin are best avoided as these are antitubercular drugs and their use may cause resistance of AFB against them), a nasal decongestant and an antihistamine may also be added to treat the infection and prevent postnasal drip. Large haemoptyses are best managed in the hospital, under the care of a specialist.
Repeated, small haemoptyses during treatment scare the patient. It’s best to talk to him about it, reassure him that his treatment is on the right lines and needs no change.
Abdominal discomfort, anorexia, nausea, vomiting
Any or all these symptoms can occur anytime during treatment. These could be either due to drug induced gastritis or drug induced hepatitis.
Gastritis
This usually occurs during the very early part of treatment. It can almost always be managed with reassurance and the addition of antacids, ranitidine, famotidine or omeprazole and domperidone or metoclopramide (if need be) to the treatment for 7-14 days or even longer.
Usually, the symptoms subside within a month and these drugs can then be withdrawn. If the symptoms do not subside, the patient can be advised to take rifampicin after breakfast instead of on an empty stomach. When even this fails (which is very rare), advise the patient to take the entire ATT at night after dinner.
Hepatitis
When the above symptoms occur in association with a sudden diminution of appetite and jaundice, drug induced hepatitis is suspected. A complete liver function test should be done. One confirmation of hepatitis, all anti TB drugs should be stopped immediately. The usual treatment of hepatitis, along with strict bed rest is instituted.
Drug induced hepatitis usually abates between 2-3 weeks. A normal liver function profile is mandatory before restarting ATT. Surprisingly, but fortunately, in almost all cases the same regime can be restarted without recurrence of hepatitis. Put the patient back on the same regime that you began with, once the hepatitis subsides.
In case the condition of the patient is so poor that discontinuing ATT during hepatitis may jeopardise his life, daily streptomycin, ethambutol and a fluoroquinolone (oflaxacin 600 mg daily or sparfloxacin 400mg daily), may be given to him till the liver function returns to normal. Then he can be put back on the same regime that he began with.
Drug induced hepatitis can be differentiated from infective hepatitis by absence of prodromal symptoms like fever and the shorter duration of jaundice.
Transient rise in serum liver enzymes are well known in early weeks of treatment. They do not warrant interruption of treatment. Liver function tests are not recommended routinely, either prior to or during treatment, as they may mislead you. However, periodic liver function tests during treatment are recommended in malnourised patients, in the elderly, in alcoholics and in patients with chronic liver disease and in those who just recovered from it.
Once the patient has recovered from hepatitis, put him back on the same regime that you began with. Don’t worry, the patient is highly unlikely to get hepatitis again!
