How to keep the liver safe while on TB treatment?

Question

I have heard that Tb medicines can be very rough on the liver. Any dietary help to keep the liver safe?

Answer 1

Definition
• Multidrug-resistant tuberculosis (MDR TB) is a form of tuberculosis that is resistant to two or more of the primary drugs used for the treatment of tuberculosis. Resistance to one or several forms of treatment occurs when the bacteria develops the ability to withstand antibiotic attack and relay that ability to their progeny.

Definition cont.
Since that entire strain of bacteria inherits this capacity to resist the effects of the various treatments, resistance can spread from one person to another. On an individual basis, however, inadequate treatment or improper use of the anti-tuberculosis medications remains an important cause of drug-resistant tuberculosis

Improper Treatment
• Improper treatment allows individual TB bacilli that have natural resistance to a drug to multiply. Eventually the majority of bacilli in the body are resistant

People at risk for MDR TB
• persons who have been exposed to someone with active MDR TB, especially if they are immunocompromised
• TB patients who have failed to take medications as prescribed
• TB patients who have been prescribed an ineffective treatment regimen
• persons who have been previously treated for TB and experience a recurrence

Cont. risk
• MDR TB has been a particular concern among HIV-infected persons. Some of the factors that have contributed to the number of cases of MDR TB, both in general and among HIV-infected individuals are:

• delayed diagnosis and delayed determination of drug susceptibility, which may take several weeks
• inadequate respiratory isolation procedures and other environmental safety conditions, especially in confined areas such as prisons

Prevalance
• MDR-TB is reported in more than 100 countries or territories
• Eight countries or provinces (Latvia, Delhi State of India, Estonia, Henan Province in China, Dominican Republic, Argentina, Ivanovo oblast of Russia, and the Ivory Coast) are "hot spots" for MDR-TB.
• In the U.S., the highest rates of MDR-TB have been found in large urban areas such as New York City, Washington, D.C., and Miami

Epidemiologic risk factors:
Incarceration, homelessness, substance abuse (alcohol or drugs), contact with someone with TB, birth outside U.S.
• Patients from countries with a high incidence of TB are more likely to be infected prior to arrival in U.S.
Epidemiologic risk factors cont.
• It is an especially formidable problem among HIV-infected patients, in whom mortality from MDR-TB can be as high as 80%.(1-2) Moreover, MDR-TB is the only AIDS-related opportunistic infection that presents a threat to the general population, because unlike PCP, CMV, and other AIDS-related OIs, MDR-TB can be transmitted to otherwise healthy people who live with, care for, or simply come into intimate contact with infected individuals.

Etiology
• Mycobacterium tuberculosis is responsible for tuberculosis infection.
• Size
• Shape
• Membrane components unique to T.B.
• Gram positive bacteria
• Nutritional Requirements/ lungs are a good spot because…
• Related to what bacteria previously studied this semester?
• Resistance is a natural phenomenon….why?
• Anti-tuberculosis medications are a man made amplification of natural phenomenon.
• No horizontal gene transfer in T.B.
• Wild strains of T.B. almost never resistant.
• Resistance develops spontaneously w/ a defined frequency
• 1 in 10^8 bacilli resistant to Rifampin
• 1 in 10^6 bacilli resistant to Isonazid

• Tubercle cavities often contain 1x10^7 T.B.
• Resistance therefore can happen in the absence of antibiotics but is diluted by drug susceptible T.B.
• Antibiotics provide selective pressure for resistant strains to dominate.
• Acquired resistance
• Primary resistance
• All drugs bound to induce resistance

• Multiple drug resistance due to spontaneous mutations virtually impossible
• Multiple drug resistance, Multiplication factor, and treatment rationale.
• Base line resistance to one drug may lead resistance to another…causing Multi-drug Resistant Strains!!!

Anatomy and Physiology
• Not just a pulmonary disease
• Can affect the genital tract, urinary tract, the heart, central nervous system, and gastrointestinal system.
• Approximately 85% of all cases affect the lungs.
• One cubic centimeter is equal to 300 cm^2. total surface area equals approximately a tennis court!

Pathophysiology
• Dissemination of T.B. outside of the lungs can lead to….
• Skeletal T.B.
• Genital tract T.B.
• Urinary Tract T.B.
• CNS T.B.
• GI T.B.
• Cardiac T.B.

Pathophysiology cont….
Most importantly the lungs

Causes inadequate oxygen diffusion between alveoli and capillary bed.

Ventilation-perfusion inequality…there may be blood flowing through areas of lung that have no ventilation.

This happens when cavitation causes scarring of the lung tissue and diffusion rate is diminished.

Finally, small amounts of volume are destroyed causing great losses of surface area.

Pathogenesis

MDR-T: same as susceptible TB

Inhalation of infected droplets of air then…

Immune system of the infected- destroys the bacteria or seals them off with the formation of tubercles at the site of infection

Rapid inflammation with polymorphonuclear leukocytes…

Tubercle bacilli drain via lung lymphatics to
-hilar lymph nodes
-thoracic duct
-possible entry to systemic venous circulation

Bacteria recirculate to the lungs causing additional local foci of infection

Organism may escape from lung capillaries to the systemic arterial circulation thus,
-infecting various organs in the body {extra pulmonary}

Genital Tract TB, Urinary tract TB, CNS TB, Gastrointestinal TB, Cardiac TB (just to name a few of the systems infected)


TB or MDR-TB more often remain dormant throughout life
-bacteria may exacerbate many years after years of initial infection
-80% of TB infections- activate dormant bacteria

Dormant bacteria usually found in scars left by initial infection
-usually found in the tops of both lungs, may begin multiply

Activation of dormant bacteria can occur when …
-Immune system becomes impaired, ex. HIV/AIDS
-Corticosteroid use
-Old age, life threatening


5% chance of developing active TB if infected within 1-2 years from initial exposure, however 90-95% of all TB infections heal without ever being noticed

A person with AIDS who becomes infected with TB has a 50% of developing active TB within 2 months
-50% chance of dieing in 2 months if the person has AIDS and TB combined

Clinical Presentation
Symptoms of MDR-TB

Nothing unique about the initial presentation of a person compared with someone with a susceptible strain

If symptoms persist despite treatment drug resistance should be suspected
.
• Symptoms: persistent cough, malaise, weight loss, anorexia, fever, bloody sputum, night sweats,
Symptoms can occur with other types of lung disease- doctor consultation is imperative
1/3 of infections manifest as pleural effusions

Extra pulmonary symptoms…kidney, bones, bladder, prostate, ovaries, fallopian tubes, from ovaries may spread to peritoneum-fatigue, vague stomach pain-with slight tenderness, to excruiating pain that resembles appendicitis

Gastrointestinal TB: uncommon today because of pasteurization of milk

Symptoms: circumferential ulcerations with stricture of the small intestine

Cardiac TB: Pericardium- common site of infection –granulomatus pericarditis that can be hemorrhagic

If extensive and chronic-fibrosis with calcification leading to constrictive pericarditis

Development of Drugs used for treatment
Streptomycin- discovered in U.S. in 1944 and was the first anti-TB drug. Was used to cure children dying of tuberculosis meningitis but found the children relapsed after a few months of treatment, because the bacteria had developed a resistance.

PAS (para-aminosalycilic acid)- brought into use in the late 1940’s. By combining both PAS and streptomycin, the drug resistant bacteria was largely prevented. However, treatment was atleast 2 years.


Isoniazid- discovered in 1952, by combining these three drugs treatment was cut down to 18 months.

Over the next 2 decades more anti-TB drugs were discovered, such as ethionamide, cycloserine, pyrazinamide, and Rifampicin.

About the drugs…
Isoniazid- is most effective drug at killing actively dividing tubercle bacilli.

Rifampicin- kills the very slowly dividing bacteria.

These two drugs alone could cure 95% of all cases

These two drugs determine if a person has multi-drug resistant TB.

The secondary drugs
Pyrazinamide, ethambutol, ethionamide, cycloserine are all useful in combination with other drugs but are troubled with side effects and poor bacteria killing ability.
Modern Treatment of TB
In practice, new patients are started on Isoniazid and Rifampicin and one other secondary drug.

Resistance?
Two drugs?

Treatment is as little as six months

Multi-drug resistant patient
Treatment of multi-resistant TB is specialized, complex, and expensive.

There are risk factors that raise the possibility of drug resistance. They are previous treatment for TB, contact with a patientinfected, immigration from an area with a high incidence rate for this disease, HIV seropositivity, substance abuse, and homelessness.

Surgical Treatment
If a patient is drug resistant and is also finding the second line of drugs to be intolerable they will consider surgery.
However, the disease has to be confined to one or two lobes at the most. The patient will then undergo a lobectomy.
This will offer a better chance of cure than continued drug treatment.

Prevention
The best prevention is to make sure that the patient is taking medication correctly.
Spread of this infection started with patients taking home three separate drugs and only taking them one at a time.
A good preventive measure would be having patients take there medication under the eye of a trained supervisor.

Answer 2

There is no specific way to keep liver safe from anti tubercular drugs. Rifampicin, pyrazinamide and Isoniazid all are toxic to liver.
Take less oily food, take multivitamin tablets, Ayurveda liver tonics like liv 52, livfit syp. etc.
But don't worry only very few get liver toxicity. So fear should not be overplayed.

Answer 3

Yes, it can be harmful. First of all, make sure that your doctor checks your liver enzymes every now and then to make sure that nothing bad is happening to the liver. If the liver tests, which can be done by taking a blood test, are normal, then its ok to take the medication.

Also, if you are taking Isoniazid, make sure to take a vitamin B6 (also called pyroxidine) vitamin. Isoniazid interferes with vitamin B6 and can affect your nerves. If you take vitamin B6 in addition, you will protect yourself from this effect.

Answer 4

Drink tea made by heating two spoons each of ajwain and jeera with two glasses of water till it reduces to one daily at around 7 p.m. to avoid liver problem.

Answer 5

Take balance diet, fresh fruits, vitamines and minerals.

Answer 6

www.nt.gov.au/health/cdc/fact_sheets/tb_treatment.pdf