More than twenty drugs have been developed for the treatment of TB. Most of them were developed some years ago. You can read about the History of TB Drugs.
The anti tubercular drugs are used in different combinations in different circumstances. For example some anti TB drugs are only used for the treatment of new patients who are very unlikely to have resistance to any of the TB drugs. There are other TB drugs, the second line drugs, that are only used for the treatment of drug resistant TB.1“Treatment of Tuberculosis guidelines”, WHO, Geneva, 2010, 85 www.who.int/tb/en/ There are now starting to be some new TB drugs, but most are still undergoing testing.
Generally anti TB drugs, that is TB medicine, is taken for the treatment of active TB or TB disease. One exception to this is when TB drugs are taken for the treatment of latent TB.
One TB drug must never be taken on it’s own. Several TB drugs, or TB medication, must always be taken together. If only one TB drug is taken then resistance may develop to the drug. This means that the drug won’t work and the patient isn’t cured.
TB drugs - the first line drugs
The five first line TB drugs are: 2“Treatment of Tuberculosis Guidelines”, WHO, Geneva, 2010, 30 www.who.int/tb/
- Isoniazid (H/Inh)
- Rifampicin (R/Rif) (In the United States rifampicin is called rifampin)
- Pyrazinamide (Z/Pza)
- Ethambutol (E/Emb)
- and Streptomycin (S/Stm)
These are the antitubercular drugs that generally have the greatest activity against TB bacteria. This medicine for TB is particularly used for someone with active TB disease who has not had TB drug treatment before. All the other TB drugs are generally referred to as second line TB drugs.
TB drug names
All the TB drug names have abbreviations which are either one, two or three letters.3Alimuddin Zumia, “Advances in the development of new tuberculosis drugs and treatment regimens”, Nature Reviews Drug Discovery, 2013 http://www.nature.com/nrd/journal/v12/n5/box/nrd4001_BX3.html There are also trade or brand names, which is the name by which a drug is known when it is being sold in a particular country and is made by a particular manufacturer.
For example ethambutol is known in India by a variety of trade names which include Abitol (made by Alpic Remedies), Actuate (made by Biocin Genetics) and Albutol (Alkem Laboratories).4“Tuberculosis - Drugs for its Treatment”
http://www.medindia.net/drugs/medical-condition/tuberculosis.htm In other countries the trade name will be different. For example, ethambutol is sometimes referred to as Myambutol. Isoniazid is sometimes called AKT4 (Lupin Laboratories).
The United States uses abbreviations and names that are not internationally recognised. For example, rifampicin is called rifampin and abbreviated RIF. For the treatment of TB in the United States only, streptomycin is no longer considered a first line TB drug.5“Tuberculosis management”, https://en.wikipedia.org/wiki/Tuberculosis_management
TB drug regimens
A regimen means a course of treatment. For TB this means a combination of TB drugs. Drug regimens are described in a standard manner. The drugs are listed by their single letter abbreviations. The order is the order that is roughly the order that they were introduced into clinical practice. The number of months that the drug should be given for is denoted by a prefix. A subscript denotes intermittent dosing, and no subscript means daily dosing. Most regimens have an initial high intensity phase followed by a continuation phase. The high intensity phase is described first and is followed by the continuation phase. A slash separates the two phases.
So 2HREZ/4HR3 means isoniazid, rifampicin, ethambutol and pyrazinamide daily for two months, followed by four months of isoniazid and rifampicin given three times a week.6“Tuberculosis management”, https://en.wikipedia.org/wiki/Tuberculosis_management
TB drug treatment for new patients
Patients who have not had any TB treatment before, or they have had less than one month of anti TB drugs, are considered to be new patients. New patients are presumed to have drug susceptible TB (i.e. TB which is not resistant to any of the TB drugs) unless there is a high level of isoniazid resistance in new patients in the area. The other people who may have drug resistant TB are people who have developed active TB disease after they have been in contact with someone who is known to have drug resistant TB.
For new patients with drug sensitive TB the World Health Organisation (WHO) recommends that they should have six months of TB drug treatment. This should consist of a two month “intensive” treatment phase followed by a four month “continuation” phase.
For the two month “intensive” TB drug treatment phase they should receive:
- Isoniazid (H/Inh)
- with rifampicin (R/Rif)
- and pyrazinamide (Z/Pza)
- and ethambutol (E/Emb)
- Isoniazid (H/Inh)
- with rifampicin (R/Rif)
for the “continuation” TB drug treatment phase.
It is essential to take several TB drugs together. If only one TB drug is taken on its own, then the patient will very quickly become resistant to that drug.
It is recommended that patients take the TB drugs every day for the six months, although taking them three times a week is possible in some circumstances. It is extremely important that all the recommended TB drugs are taken for the entire time. The amount of any drug that a patient needs to take depends on the patient’s weight.
The treatment probably won’t work if only one or two of the TB drugs are taken, or if the treatment is interrupted or stopped early. This is because the TB bacteria develop resistance to the TB drugs. The patient is then still ill, and to be cured they then have to take drugs for the treatment of drug resistant TB.
TB drugs for the treatment of drug resistant TB
Change of recommendations in May 2016
In May 2016 the WHO changed their recommendations on the use of TB drugs for the treatment of drug resistant TB.7“WHO treatment guidelines for drug-resistant tuberculosis (2016 update)”, http://www.who.int/tb/areas-of-work/drug-resistant-tb/treatment/resources/en/ This was partly because of the Bangladesh regimen, which appeared to show that a shorter regimen could be just as successful as a longer regimen.8Van Deun, A et. al. “Short, highly effective and inexpensive standardized treatment of multidrug-resistant tuberculosis”, Am J Respir Crit Care Med 2010; 182:684-692 http://www.atsjournals.org/doi/full/10.1164/rccm.201001-0077OC There had also been a number of other studies which had shown a similar result. There had however been no randomized control trial, but WHO decided that the treatment of MDR-TB was too important for there not to be new recommendations.
More information on the new recommendations can be found on the page on the Treatment of drug resistant TB.
Side effects of TB drugs
The side effects of TB drugs depends on the exact combination of drugs that are being taken. The side effects can range from mild to severe.
One drug with a particularly severe side effect is Streptomycin. This drug can cause people to become deaf and it should be avoided if at all possible.