Management of Anti-tubercular therapy (ATT) induced Hepatitis

Definition of ATT induced hepatitis

1. ALT > 3 X Normal + Symptoms OR
2. ALT > 5 X Normal without Symptoms

Management of ATT induced hepatitis

1. Hold all TB drugs for 7-10 days. Wait before restarting ATT until:

• Symptoms: Resolve
• ALT <2.5 X Normal

For severe TB, patients should be started on SEQ (Streptomycin, Ethambutol and Quinolone) until first line drugs can be re-introduced.

2. Re-introduce first line ATT in a stepwise manner:

• Start full dose Ethambutol (it is non-hepatotoxic) from Day 1
• Day 1-3: E + H (1/3rd-full dose)
  • Start Isoniazid and increase the dose in subsequent days, i.e. 1/3rd, 2/3rd then full dose
  • Perform LFT at Day 3
• Day 4-6: E + H + R (1/3rd-full dose)
  • Start Rifampicin and increase the dose in subsequent days, i.e. 1/3rd, 2/3rd then full dose
  • Perform LFT at Day 6
• Day 7-9 (only if patient has no liver disorder): E + H + R + Z (1/3rd-full dose)
  • Start Pyrazinamide and increase the dose in subsequent days, i.e. 1/3rd, 2/3rd then full dose
  • Perform LFT at Day 9
• If patient is symptomatic or LFT is deranged at any stage, offending drug must be stopped.

3. Duration of treatment depends on the number of drugs given.

Reference: National-Tuberculosis-Management-Guidelines-2019_Nepal.pdf (nepalntp.gov.np)