PULMONARY TUBERCULOSIS TREATMENT

Tuberculosis treatment is divided into 2 phase: Intensive phase and continuation phase.
Intensive phase is given every day for at least 2 months in order to kill and reduce the number of
bacteria in patients’ body. If the intensive phase were done regularly, the level of transmission
would be decreased in 2 weeks of treatment. Meanwhile, the continuation phase is given in a
longer period of time but with less number of drugs. This phase aims to kill the remaining
bacteria that still exist in patients’ body and to prevent recurrence. 1
The goals of tuberculosis treatment are not only to cure and to improve patients’
productivity and quality of life, but also to prevent mortality due to the disease, to prevent
recurrence, and to reduce transmission and occurrence of TB and MDR-TB. 1.
Adequate tuberculosis treatment must be given in a combination of minimum 4 kinds of Anti
Tuberculosis Drug to prevent the occurrence of resistance. The treatment must be given in an
appropriate dose and adequate length of time and also must be administered regularly under
direct supervision of the Tuberculosis Treatment Supervisor (Pengawas Minum Obat) until the
end of treatment course. Tuberculosis drug in the form of the Fixed Dose Combination (FDC) is
more recommended.
Drugs used in tuberculosis treatment consist of: Rifampicin, Isoniazid, Pyrazinamide,
streptomycin, and ethambutol. Some patients may experience some side effects from these drugs
listed in table 2 and table 3.

Table 1. First Line Anti Tuberculosis Drugs

Recommended Dose (mg/kg)
Drug Name MOA
Daily 3x a week
Isoniazid Bactericide 5 (4-6) 10 (8-12)
Rifampicin Bactericide 10 (8-12) 10 (8-12)
Pyrazinamide Bactericide 25 (20-30) 35 (30-40)
Streptomycin Bactericide 15 (12-18) 15 (12-18)
Ethambutol Bacteriostatic 15 (15-20) 30 (20-35)

Table 2. Mild side effect of Anti Tuberculosis Drugs

Drug Side Effect Solution
Rifampicin Lack of appetite, nausea, Take drug at night before
abdominal pain sleep
Pyrazinamide Joint pain Give aspirin/allopurinol
Isoniazid Tingling sensation, give vitamin B6 (pyridoxine)
 sometimes burn sensation 100 mg/day
in lower extremities
Rifampicin Red urine Give explanation, no need
to give anything

Table 3 severe side effect of Anti Tuberculosis Drugs

Drugs Side effect Solution
All Anti Tuberculosis Itchy and red skin Give antihistamine and
Drugs supervision
Streptomycin deafness Stop administration
Streptomycin Balance disorder Stop administration
Almost all Anti icteric Stop administration of
Tuberculosis Drugs all drugs until icteric
resolves
Almost all Anti Confusion and Stop administration of
Tuberculosis Drugs vomitting all drugs and perform
liver function test
Ethambutol Vision impairment Stop administration
Rifampicin Purpura and shock Stop administration

According to the National Guidance of Tuberculosis Treatment in Indonesia (Pedoman

Nasional Pengendalian Tuberkulosis, di Indonesia) there are 3 categories of anti-tuberculosis
drug combinations.
 Category 1 : 2(RHZE)/4(HR)3
 Category 2 : 2(RHZE)S/(RHZE)/5(RH)3E3
 Category pediatric : 2(RHZ)/4(RH) or 2RHZE(S)/4-10RH
Category 1 and 2 is available in the form of FDC containing combination of 2 or 4 drugs in
1 tablet, and in the form of combipack which consists of the 4 drugs given individually in a
blister form. This form is usually given to patients’ experiencing side effects from FDC.
 Category 1: 2(RHZE)/4(HR)3
Given to new patient that is bacteriologically confirmed, or clinically diagnosed, or to new
patient infected with extra pulmonary TB.
Table 4 category 1 FDC dose
Body weight Intensive phase Continuation phase
Every day for 56 days 3 times a week for 16 weeks
RHZE (150/75/400/275) RH (150/150)
30 – 37 kg 2 tablet 4FDC 2 tablet 2FDC
38 – 54 kg 3 tablet 4FDC 3 tablet 2FDC
 55 – 70 kg 4 tablet 4FDC 4 tablet 2FDC
≥ 71 kg 5 tablet 4FDC 5 tablet 2FDC

Table 5 category 1 combipac dose

Phase Duration Dose per day/ 1x swallow Total of
Tablet Caplet Tablet Tablet
days
Isoniazid Rifampicin Pyrazinamide Ethambutol
swallowing
@ 300 @ 450 mgr @ 500 mgr @ 250 mgr
drug
mgr
Intensive 2 months 1 1 3 3 56
continuation 4 months 2 1 - - 48

 Category 2: 2(RHZE)S/(RHZE)/5(RH)3E3
Given to patient with positive AFB that has received previous treatment including patient
with category 1 treatment failure, patient with recurrence, and lost to follow-up patients.

Tabel 6 category 2 FDC dose

Body Intensive phase Continuation phase
weight Daily 3 times a week
RHZE (150/75/400/275) + S RH (150/150) + E (400)
For 56 days For 28 days For 20 weeks
30 – 37 kg 2 tablet 4FDC 2 tablet 4FDC 2 tablet 2FDC
+ 500 mg streptomycin inj. + 2 tablet ethambutol
38 – 54 kg 3 tablet 4FDC 3 tablet 4FDC 3 tablet 2FDC
+ 750 mg streptomycin inj. + 3 tablet ethambutol
55 – 70 kg 4 tablet 4FDC 4 tablet 4FDC 4 tablet 2FDC
+ 1000 mg streptomycin + 4 tablet ethambutol
inj.
≥ 71 kg 5 tablet 4FDC 5 tablet 4FDC 5 tablet 2FDC
+ 1000 mg streptomycin ( > max dose) + 5 tablet ethambutol
inj.

Tabel 2.7 category 2 combipac dose

Phase Duration Tablet Caplet Tablet Ethambutol Streptomycin Total of
Tablet Tablet
isoniazid rifampisin pirazinamid injection days
@ 250 @ 400
@ 300 @ 450 @ 500 mgr swallowing
mgr mgr
mgr mgr
drug
Intensive 2 bulan 1 1 3 3 - 0.75 gr 56
1 bulan 1 1 3 3 - 28
continuation 5 bulan 2 1 - 1 2 - 60
 MONITORING
Monitoring for improvement of treatment is done with sputum test and will be better if
accompanied by radiologic imaging. Monitoring is usually done in the end of intensive phase
( second month or third month, depends on treatment category), on the fifth month and in the end
of treatment course.
The monitoring process require 2 sputum specimens, if both specimen show negative
results, the test result is concluded to be negative. Meanwhile, if one or both of the specimen
show positive result, the test result is concluded to be positive.
In new case of TB patient that received category 1 treatment, if the result of sputum test
is still positive in the end of intensive phase (second month), the continuation phase should still
be given followed by another sputum test in the end of the first month of continuation phase
(third month). If the result is, too, still positive, we should do a culture or drug sensitivity test. If
not possible for drug sensitivity test, we continue the continuation phase, and do sputum test in
the fifth month. If the result is still positive at that time, the treatment is determined as treatment
failure, and the patient is declared as a MDR-TB suspect, and should start category 2 drugs from
the start.
Meanwhile in TB patient with category 2 treatment, if in the end of intensive phase (third
month) the sputum test is positive, the patient is declared as MDR-TB suspect. We should do a
culture or drug sensitivity test. If not possible for drug sensitivity test (DST), we continue the
continuation phase, and do sputum test in the fifth month. If the result is still positive at that
time, the treatment is determined as treatment failure and it is really a necessary to do DST or a
referral to MDR-TB referral hospital. We should also educate the patient about how serious the
disease they are having and how important it is to follow the treatment as a way to control TB
transmission and infection.

PROGNOSIS
Prognosis of tuberculosis in general is good unless the disease is complicated with comorbidities
or resistance. However, with good adherence and a completed treatment, the outcome of
tuberculosis can be improved.

HOSPITAL VISIT OBSERVATION

Mr. John Mamuaya, 52 years old, is now on treatment for tuberculosis and HIV. He is now on the
fifth month of tuberculosis treatment, which means he is in the continuation phase. He received
the drugs in the form of 2FDC. He experienced change in his urine color, but he is already told
that it is a normal side effects of the drug he’s taking. He doesn’t experience any other side
effects. His kidney ultrasound result is also in normal condition.
We didn’t go further about his HIV medication.

1. Kemenkes RI. Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan:

Pedoman Nasional Pengendalian Tuberkulosis. Jakarta; 2014. 1-148 p.