What are the RNTCP (Revised National Tuberculosis Control Programme) ATT (Anti-Tuberculosis Treatment) guidelines for tuberculosis treatment?

RNTCP ATT Guidelines for Tuberculosis Treatment

The Revised National Tuberculosis Control Programme (RNTCP) recommends directly observed therapy short course (DOTS) strategy for the treatment of both adult and pediatric tuberculosis, with regimens consisting of isoniazid, rifampin, pyrazinamide, and ethambutol as first-line drugs. 1

Drug-Susceptible Tuberculosis Treatment

Initial Treatment Regimen

• A 4-drug regimen of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) is the preferred initial treatment for drug-susceptible pulmonary tuberculosis 2
• Treatment should be initiated promptly even before AFB smear microscopy, molecular tests, and mycobacterial culture results are known in patients with high likelihood of having tuberculosis 2

Treatment Duration

• Standard treatment consists of a 2-month intensive phase followed by a 4-month continuation phase 2
• For culture-negative, paucibacillary tuberculosis in HIV-uninfected adults, a 4-month treatment regimen (2-month intensive phase followed by 2-month continuation phase) may be adequate 2

Dosing Options

• Daily dosing: Isoniazid 5 mg/kg (up to 300 mg) daily; rifampin as per weight; pyrazinamide and ethambutol as per weight 3
• Intermittent dosing: Isoniazid 15 mg/kg (up to 900 mg) two or three times weekly; other drugs adjusted accordingly 3
• RNTCP provides fixed drug combinations (FDCs) and patient-wise boxes (PWBs) to simplify prescription and improve adherence 1, 4

Drug-Resistant Tuberculosis Treatment

MDR-TB Treatment

• Intensive phase should last 5-7 months after culture conversion 5
• Total treatment duration of 15-21 months after culture conversion 5
• At least five effective drugs in the intensive phase and four drugs in the continuation phase 2

XDR-TB Treatment

• Treatment duration extended to 15-24 months after culture conversion 6, 5
• Regimen should include bedaquiline, a later-generation fluoroquinolone (if susceptible), linezolid, and clofazimine as core components 6

Essential Drugs for MDR/XDR-TB

• Bedaquiline is strongly recommended as a core component 6, 5
• Later-generation fluoroquinolone (levofloxacin or moxifloxacin) if susceptibility is confirmed 6
• Linezolid, clofazimine, and cycloserine are recommended effective components 6
• Pyrazinamide should only be included if susceptibility is confirmed 6

Special Considerations

Pediatric Tuberculosis

• Children require weight-based dosing: Isoniazid 10-15 mg/kg (up to 300 mg) daily; or 20-40 mg/kg (up to 900 mg) two or three times weekly 3
• Ethambutol should be used with caution in children whose visual acuity cannot be monitored 3
• RNTCP has revised upward the dosages of anti-TB drugs for children to ensure optimal drug levels 4

HIV Co-infection

• Therapeutic decisions for HIV co-infected patients must be individualized due to potential malabsorption issues 3
• Screening of antimycobacterial drug levels may be necessary, especially in patients with advanced HIV disease 3

Extrapulmonary Tuberculosis

• Basic principles of pulmonary TB treatment apply to extrapulmonary forms 3
• Military tuberculosis, bone/joint tuberculosis, and tuberculous meningitis in children should receive 12-month therapy 3

Monitoring and Follow-up

Treatment Response Monitoring

• Sputum culture conversion is a positive predictor of successful treatment outcome 7
• Female gender, sputum culture conversion from positive to negative, and radiological improvement are positive predictors of successful treatment 7

Common Pitfalls to Avoid

• Using fewer than five effective drugs in MDR-TB treatment leads to poorer outcomes 6, 5
• Smoking and alcohol consumption are negative predictors of successful treatment outcome 7
• Low rifampicin concentrations, low body weight, alcohol use, male gender, and baseline INH resistance significantly increase the likelihood of unfavorable outcomes 8

Adverse Drug Reactions

• Joint pain due to pyrazinamide and neurological/psychiatric disturbances due to cycloserine are common adverse reactions requiring drug withdrawal 7
• Regular monitoring for adverse effects is essential, particularly for second-line drugs 7

Recent Updates in RNTCP

• Universal drug sensitivity testing (U-DST) for all TB cases to guide treatment 4
• Addition of ethambutol to the continuation phase of first-line therapy due to high initial isoniazid resistance 4
• Replacement of standard retreatment regimen (category II) with specific therapy based on resistance patterns 4
• Implementation of newer diagnostic methods like cartridge-based nucleic acid amplification tests (CBNAAT) and line probe assays (LPA) 4