ANTI TB DRUGS SIDE EFFECTS

Common side effects

DRUG SIDE-EFFECTS
Isoniazid Hepatitis, peripheral neuropathy
Rifampicin Flu-like syndrome, dermatitis, hepatitis,
reddish-brown colouration of urine
Pyrazinamide Joint pains, hepatitis
Ethambutol Impaired visual acuity and colour vision
Streptomycin Headache, tinnitus, skin itching and
rash

Management of side effects

SIDE-EFFECTS DRUG(S) LIKELY
TO CAUSE
MANAGEMENT
Low appetite,
nausea,
abdominal pain
Pyrazinamide,
Rifampicin
Give drugs with
small meal or just
before going to bed
Joint pains Pyrazinamide Give an analgesic
e.g. ibuprofen or
Paracetamol
Burning
sensation in the
feet
Isoniazid Pyridoxine 25-100
mg daily
Orange/red urine Rifampicin Reassure the
patient that it is not
harmful
Skin rash
(hypersensitivity
reaction)
Any anti-TB
drug
Depending
on degree, see
guidelines below
Deafness (no wax
on auroscopy)
Dizziness,
vertigo, and
nystagmus
Streptomycin Stop streptomycin.
Use Ethambutol
Jaundice (other
causes excluded)
Pyrazinamide,
Rifampicin and
Isoniazid
Stop anti-TB drugs
see guidelines
below
Mental confusion Isoniazid,
Rifampicin and
Pyrazinamide
  1. If jaundiced,
    suspect liver failure,
    stop drugs (see
    below)
  2. If no jaundice,
    suspect Isoniazid,
    increase dose of
    pyridoxine
Visual
impairment
(other causes
excluded)
Ethambutol Stop Ethambutol.
Use streptomycin

Hypersensitivity reaction

Most anti-TB drugs can cause hypersensitisation between week 3 and week 8 of treatment in order of frequency:
ethambutol, pyrazinamide, rifampicin and isoniazid.

If mild (simple itchy rash), give antihistamine (e.g. chlorpheniramine) and moisturizer and continue treatment.

Severe reactions are characterised by

  • Fever, headache, vomiting
  • Macular dark erythematous rash which can progress to a Steven Johnson-Toxic Epidermal Necrolysis syndrome

TREATMENT

  • Stop all drugs immediately
  • Manage supportively
  • Refer for specialised management

Drug-induced hepatitis

Severe hepatic damage, presenting with jaundice, vomiting, severe malaise. In order of frequency, the implicated drugs
are Isoniazid, Pyrazinamide, Rifampicin and Ethambutol.

TREATMENT

  • Stop all drugs immediately
  • Manage supportively
  • When jaundice has resolved, re-introduce single drugs at 3-7 days interval, starting from the least likely involved
  • If reaction very severe, do not try to restart pyrazinamide. If RH tolerated, do not try pyrazinamide
  • Use alternative regimen avoiding the causative drug