25%

95%

69%

31%

50%

2%7%

33%25%

2%

24%

36%

TB ilma ravita TB hea ravikorraldus MDR TB ravi XDR-TB ravi

ParanemineSurm

Krooniline kulg

Results of the TB treatment

Drug-sensitive cases -- at least 85% should be curedMDRTB - over 70% cured

XDR-TB- 30-40 % should be curedTB/HIV coinfection- results are on lower level

lTREATMENT REGIMENS

The preferred regimen for active drug-sensitive TB disease isminimum of 6 months

First 2 months (the intensive phase of treatment),rifampicin, isoniazid, pyrazinamide, ethambutol

followed by isoniazid and rifampicin for 4 months (the continuation phase of treatment)

Relaps - 8 months3 months - 5 drugs5 months - 3 drugs

Treatment efficacy and progress are usually monitored with repeat sputum smears, cultures and chest X-rays.

TB treatment is free for all persons in Estonia, despite of livingplace and having health insurance or not

• The optimal dosing frequency is daily throughout the course of therapy

• Dosing of anti-TB drugs is based on the weight of the patient.

• Monthly monitoring of patient body weight is important, medication dose should be adjusted.

• Once-daily dosing is mandatory for anti-TB drugs from Group 1, 2, and 3, as this is thought to improve the peak-dependent killing.

• Twice-daily dosing is an excellent strategy to reduce adverse effects of Group 4 drugs.

• Many patients can tolerate a full dose of ethionamide and cycloserine once daily Traditionally they have been given twice daily to reduce adverse effects.

• Once-daily dosing is allowed for Group 4 drugs. There are no studies comparing once-daily to twice-daily dosing for Group 4 drugs in terms of efficacy.

Drug dosing freaquency

The common adverse events are mild increases in the level of liver enzymes, skin rash, gastrointestinal intolerance, neuropathy and arthralgia and can be managed symptomatically without discontinuation of the offending drugs. Serious adverse events are severe hepatitis, immune thrombocytopaenia, agranulocytosis, haemolysis, renal failure, optic neuritis and ototoxicity.

prolonged therapy undermines patient compliance. As a result, supportive measures are necessary to ensure optimal adherence, as lack of treatment completion contributes to treatment failure, relapse and the emergence of drug resistance.

Symptom-based approach to managing side-effects of anti-TB drugs

1. Rapidly multiplying→ INH H>>SM>R>E

2. Slowly multiplying→ PZ Z>>R>H

3. Intermittent growth→ RIF R>>H

Bactericidal activity

The action of anti-tuberculosis drugs

Total duration of MDR-TB treatment Treatment should continue for a minimum of

20 months and at least 18 months after the patient becomes culture-negative

Chronic patients with extensive pulmonary disease may require MDR-TB treatment for 24 months or longer.

A 9–12-month regimen (conditional WHO recommendation with very-low-quality evidence) might be used in selected patients, in appropriate settings, taking into account previous treatment and local resistance profiles

Medicines recommended for the treatment of rifampicin-resistant and multidrug-resistant TB1

Directly Observed Treatment, DOTThe most common adherence monitoring approach is directly observed therapy (DOT)

• Every dose of treatment is directly supervised by a health professional, although the effectiveness of this measure is controversial.

• Although DOT continues to be valuable in many settings, various alternative methods are now being tried out to improve adherence

o mobile phone reminders, o smart pill boxes, o video DOT and the use of call centres to follow-up with patients.

• Regardless of the method, it is crucial to use a team-based, patient-centric approach that incorporates education, counselling and patient empowerment.

Surgical treatment

It remains one of the treatment options for TB. Surgery has been employed in treating TB patients since before the

advent of chemotherapy

Segmentectomie, lobectomie, atypical resection, pulmonectomy

Partial lung resection for patients with MDR-TB is only to be considered under conditions of good surgical

Facilities, trained and experienced surgeons and with careful selection of candidates.

Treatment with TB drugs after hte surgeryDrug sensitive TB case : 4-6 monthsMDR-TB: 9-12 months

S

TB treatment before the surgery- 1 year After the surgery - 11 months

Аgnessa 29 yearsX-ray:10.01.2011 - before the surgery

TB treatment. EPTB A 6 to 9-month regimen is recommended as initial therapy for all

forms of extrapulmonary tuberculosis unless the organisms are known or strongly suspected to be resistant to the first-line drugs.2 months of isoniazid, rifampicn, pyrazinamide, ethambutol, 4 -7 months of isoniazid and rifampin

For patients with CNS tuberculosis, including meningitis,at least nine to 12 months of therapy is recommended.

Extended therapy also may be required for patients with bone and joint tuberculosis, delayed treatment response, or drug resistance.

Adjunctive corticosteroids may be useful in patients who have tuberculous meningitis, tuberculous pericarditis, or miliarytuberculosis with refractory hypoxemia.

Treatment success of all TB cases, EU/EEA, 2014

16* Four EU/EEA Member States did not report treatment outcome data

0 10 20 30 40 50 60 70 80 90 100

EU/EEALuxembourg

CroatiaCyprusFinland

DenmarkIrelandPoland

GermanyLithuania

Czech RepublicAustriaEstonia

PortugalHungary

MaltaSpainLatvia

SloveniaBelgium

RomaniaUnited Kingdom

BulgariaNorway

NetherlandsSwedenIceland

Slovakia

Treatment success (%)

Source: European Centre for Disease Prevention and Control. TB surveillance and monitoring in Europe, 2016.

74.0% of all TB cases* had a successful treatment outcome after 12 months (range 0.0–92.8%)

Indicator 7: Treatment success rate new pulmonary culture positive MDR TB cases*

17 * Luxembourg reported ‘zero’ cases; France, Greece, and Italy did not report treatment outcome results.

Source: European Centre for Disease Prevention and Control. TB surveillance and monitoring in Europe, 2016.

Target: Treatment success of 70% for new pulmonary culture-positive MDR TB cases

Status 2014: Success rate in EU/EEA was 55.6% (range 0–100.0%), target met by 6 countries

Treatment outcomes in MDR TB notified in 2010-2012, EU/EEA, 2014

18

0

10

20

30

40

50

Success Died Failed Defaulted orunknown

Still ontreatment

Perc

enta

ge MDR TB cohort 2010 MDR TB cohort 2011 MDR TB cohort 2012

Source: European Centre for Disease Prevention and Control. TB surveillance and monitoring in Europe, 2016.

Treatment success rates increased from 32% to 40% in the 2010, 2011 and 2012 cohorts

Additional support

Since 2011 the NTP allocates additional finances for provision of voluntary treatment of Alcohol Use Disorders and/or drug abuse (including methadone substitution treatment,

naltrexone, disulfiram etc.) psycho-social counselling support together with TB treatment

These additional services are given by a team consisting of social workers, psychologist, psychiatrist

and they belong to this department.

Treatment outcomes in MDR TB notified in 2012, EU/EEA, 2014

20

≥ 70%

40 to 69.9%

< 40%

Not reporting

* Cyprus, Luxembourg, Malta and Slovenia reported zero MDR TB cases in 2012. Nine Member States did not report treatment outcome data for MDR TB cases.

Source: European Centre for Disease Prevention and Control. TB surveillance and monitoring in Europe, 2016.

The success rate was 40,3% (treatment started in 2012 )