What is the cause of vomiting in a patient undergoing Anti-Tuberculosis Treatment (ATT)?

From the Guidelines

For a patient who develops vomiting with anti-tuberculosis treatment (ATT), I recommend evaluating the symptoms for possible hepatotoxicity and managing them with antacids or antiemetics, while considering temporary discontinuation of the offending drug(s) if necessary, as suggested by the American Thoracic Society guidelines 1. The cause of vomiting in a patient undergoing ATT can be multifactorial, but gastrointestinal reactions are common, especially early in therapy 1.

• Gastrointestinal intolerance not associated with hepatotoxicity can be treated with antacids, which have less impact on absorption or peak concentration of first-line drugs than administration with food 1.
• Any combination of otherwise unexplained nausea, vomiting, and abdominal pain should be evaluated with a physical examination and liver function tests to assess for possible hepatotoxicity 1.
• Drug-induced hepatitis is the most frequent serious adverse reaction to the first-line drugs, and INH, RIF, and PZA can cause drug-induced liver injury (DILI) 1.
• If hepatotoxicity is suspected, the offending drugs should be stopped immediately, and the patient should be evaluated carefully 1. It is essential to monitor liver function tests, as vomiting may also indicate drug-induced hepatotoxicity, particularly if accompanied by jaundice or abdominal pain 1.
• Patients receiving SAT may take the medications at bedtime to minimize symptoms, and taking medications with a small meal (not on an empty stomach) and dividing the doses throughout the day may help reduce nausea. Severe or persistent vomiting requires prompt medical attention, as it can lead to inadequate drug absorption and treatment failure 1.

From the Research

Causes of Vomiting in Patients Undergoing Anti-Tuberculosis Treatment (ATT)

• Vomiting in patients undergoing ATT can be caused by drug-induced liver injury (DILI) 2, which is one of the most common adverse reactions of anti-tuberculosis treatment.
• The risk factors for DILI include NAT2 slow acetylation genotype, GSTM1 gene variation, advanced age, hepatitis virus infection or concurrent acute/chronic liver disease, HIV infection, malnutrition, and alcohol (ethanol) intake 2.
• Other adverse effects of anti-tuberculosis drugs that can cause vomiting include hepatotoxicity, dermatological reactions, gastrointestinal intolerance, hematological reactions, and renal failure 3.
• Drug fever caused by anti-tuberculosis drugs can also lead to vomiting, with symptoms including high fever, rash, chills, headache, stuffy nose, runny nose, nausea, and joint pain 4.

Treatment of Vomiting in Patients Undergoing ATT

• The treatment of vomiting in patients undergoing ATT depends on the underlying cause, with DILI requiring immediate discontinuation of the suspected drug and monitoring of liver function 2.
• For drug fever, the suspected drugs should be withdrawn, and patients with complications should be treated according to the principles of complications treatment 4.
• Anti-emetic drugs such as metoclopramide, ondansetron, and bromopride can be used to treat vomiting in children with acute gastroenteritis 5, 6, but their effectiveness in patients undergoing ATT is not well established.

Management of DILI in Patients Undergoing ATT

• The management of DILI in patients undergoing ATT involves a comprehensive medical history collection, liver biochemical tests, abdominal imaging, and liver histopathological examination 2.
• The diagnosis of DILI requires a history of exposure to anti-tuberculosis drugs, rapid normalization of abnormal liver biochemical markers after drug discontinuation, exclusion of other causes of liver injury, and a positive rechallenge reaction 2.
• The treatment of DILI involves the use of hepatoprotective drugs, such as bicyclol and magnesium isoglycyrrhizinate, and the avoidance of concurrent hepatotoxic drugs 2.