Multiple-Drug Therapy for Tuberculosis (TB)

Examples

First-choice medicines:

Generic Name Brand Name
ethambutol Myambutol
isoniazid  
pyrazinamide  
rifabutin Mycobutin
rifampin Rifadin, Rimactane
rifapentine Priftin

Second-choice medicines:

Generic Name Brand Name
amikacin  
capreomycin Capastat Sulfate
cycloserine Seromycin
ethionamide Trecator
levofloxacin Levaquin
moxifloxacin Avelox
para-aminosalicylic acid Paser
streptomycin  

Combination medicines:

Generic Name Brand Name
isoniazid plus pyrazinamide plus rifampin Rifater
isoniazid plus rifampin Rifamate

How It Works

These antibiotics kill the bacteria that cause tuberculosis (TB).

Multiple-drug therapy to treat TB means taking several different antibiotics at the same time. This is the first choice of treatment for TB that is growing in your body (active TB disease). Most of these medicines are given as pills. The American Thoracic Society, Centers for Disease Control and Prevention, and the Infectious Diseases Society of America recommend using one of several combinations of the first-choice medicines to start treatment.1

The standard treatment is to take isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months. Treatment is then continued for at least 4 months with fewer medicines. Also, there are special treatment recommendations for people with HIV and TB, people with drug-resistant TB, children with active TB, and pregnant women with active TB.

Prepared combination medicines, such as Rifater, are usually used when there is a need for fewer numbers of pills, such as when a health professional is not giving each dose of medicine personally. Combining antibiotics into a single pill makes it less likely that you will miss taking any doses. Failure to take a medicine could prolong your treatment and increase your chance of developing drug-resistant TB.

Streptomycin usually is given only to people who cannot take ethambutol.

Some antibiotics (such as isoniazid or rifampin) may be taken alone to prevent a latent TB infection from turning into active TB disease, which can spread to other people.2 Or two or more antibiotics may be taken together to help prevent latent TB from becoming active TB.3 You typically would take the single antibiotic for a longer time (6 to 9 months) than the combination of antibiotics (3 months).

Why It Is Used

Treatment with several medicines makes it more likely that all TB-causing bacteria will be killed. The combination of medicines and the length of treatment may change based on:

How Well It Works

Treatment for active TB disease

The standard treatment for TB using a combination of four medicines is very effective. Almost everyone infected with TB bacteria that can be killed by the medicines are cured if they take the medicines exactly as they should.4, 5 The cure rate for people who have TB and HIV is similar to that for people who have only TB.4

It takes at least 6 months of treatment for a cure. It could take longer if doses are missed. It can also take longer if the disease does not respond well to the medicine.

Treatment for latent TB infection

Treatment with isoniazid alone for 6 to 12 months will prevent active TB disease in most people who have a latent TB infection.1

Also, taking a combination of two antibiotics for 3 months is an effective way to treat latent TB.3 For this treatment, a health professional watches you take each dose of antibiotics, which helps prevent the TB bacteria from getting resistant to the antibiotics.

Side Effects

All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine.

Here are some important things to think about:

  • Usually the benefits of the medicine are more important than any minor side effects.
  • Side effects may go away after you take the medicine for a while.
  • If side effects still bother you and you wonder if you should keep taking the medicine, call your doctor. He or she may be able to lower your dose or change your medicine. Do not suddenly quit taking your medicine unless your doctor tells you to.

Call 911 or other emergency services right away if you have:

  • Trouble breathing.
  • Swelling of your face, lips, tongue, or throat.

Call your doctor right away if you are taking isoniazid, rifampin, or pyrazinamide and you develop:

  • Hives.
  • Loss of appetite, nausea, or vomiting.
  • Skin rash.
  • Yellow color to your skin (jaundice).
  • A general feeling of being ill.
  • A fever that lasts for 3 or more days with no obvious cause, such as a cold or the flu.
  • Tenderness or soreness in your belly.

Call your doctor right away if you are taking ethambutol and you develop:

  • Blurred vision or changes in the way you see colors.

Call your doctor right away if you are taking levofloxacin or moxifloxacin and you develop:

  • Sudden pain or swelling around your ankle, shoulder, elbow, or hand. These medicines increase the risk of a tendon rupture or other tendon damage. Do not exercise until your doctor says it is okay.

Rifampin colors your urine, sputum, sweat, and tears orange-red. This is normal. The color will go away when you stop taking the medicine. But it will stain your clothing and your contact lenses.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

It is important to take all of the medicines during your treatment to ensure the infection is cured, to protect others from TB, and to reduce the risk of a relapse.

It is best to take these medicines without food. But if they upset your stomach, you can take them with food.

Do not drink alcohol during treatment for TB, because it can increase your risk of liver damage.

Before and sometimes during treatment with these medicines, you may have tests to check your liver.

If you have active TB, the health department will test people who work or live with you to see if they have a TB infection. If they have TB, they will get treated to prevent the spread of the disease.

A health professional may have to watch you take all doses of your medicines. This is called directly observed therapy (DOT), and it helps make sure that people take their medicines exactly as they are supposed to. As a result, cure rates for TB have significantly improved.1 If medicine is not taken as prescribed, drug resistance may develop. If this happens, the bacteria become harder to kill.

If you must be in the hospital during TB treatment, you will be in a special room that filters the TB bacteria out of the air. This will prevent health care workers and other people in the hospital from getting a TB infection. You probably will not be able to leave the room until you have 3 sputum samples that show you can no longer spread the infection.

Taking medicine

Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.

There are many reasons why people have trouble taking their medicine. But in most cases, there is something you can do. For suggestions on how to work around common problems, see the topic Taking Medicines as Prescribed.

Advice for women

If you are pregnant, breast-feeding, or planning to get pregnant, do not use any medicines unless your doctor tells you to. Some medicines can harm your baby. This includes prescription and over-the-counter medicines, vitamins, herbs, and supplements. And make sure that all your doctors know that you are pregnant, breast-feeding, or planning to get pregnant.

A woman can breast-feed her baby during TB treatment without worrying that the medicines will harm the baby.

Streptomycin, rifapentine, and capreomycin

Do not use this medicine if you are pregnant or planning to get pregnant. If you need to use this medicine, talk to your doctor about how you can prevent pregnancy.

Checkups

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.

Complete the new medication information form (PDF)new medication information form (PDF)(What is a PDF document?) to help you understand this medication.

References

Citations

  1. American Thoracic Society, Centers for Disease Control and Prevention, Infectious Diseases Society of America (2003). Treatment of tuberculosis. American Journal of Respiratory and Critical Care Medicine, 167(4): 603–662.
  2. Fitzgerald D, et al. (2010). Mycobacterium tuberculosis. In GL Mandell et al., eds., Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed., vol. 2, pp. 3129–3163. Philadelphia: Churchill Livingstone Elsevier.
  3. Centers for Disease Control and Prevention (2011). Recommendations for use of an isoniazid-rifapentine regimen with direct observation to treat latent Mycobacterium tuberculosis infection. MMWR, 60(48): 1650–1653. Available online:
  4. Tuberculosis Coalition for Technical Assistance (2006). International standards for tuberculosis care (ISTC). Available online: http://www.who.int/tb/publications/2006/istc_report.pdf.
  5. Jindani A, et al. (2004). Two 8-month regimens of chemotherapy for treatment of newly diagnosed pulmonary tuberculosis: International multicentre randomised trial. Lancet, 364(9441): 1244–1251.

Credits

By Healthwise Staff
E. Gregory Thompson, MD - Internal Medicine
R. Steven Tharratt, MD, MPVM, FACP, FCCP - Pulmonology, Critical Care Medicine, Medical Toxicology
Last Revised April 4, 2013

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