What are the recommended Anti-Tuberculosis Treatment (ATT) doses for drug-susceptible tuberculosis?

Recommended Anti-Tuberculosis Treatment (ATT) Doses for Drug-Susceptible Tuberculosis

For drug-susceptible tuberculosis, the recommended daily doses for adults are: isoniazid 5 mg/kg (typically 300 mg), rifampin 10 mg/kg (typically 600 mg), pyrazinamide 15-30 mg/kg (maximum 2g), and ethambutol 15-25 mg/kg. 1, 2

First-Line Drug Dosing for Adults

Daily Dosing (Preferred Regimen)

• Isoniazid: 5 mg/kg (typically 300 mg) daily 1
• Rifampin: 10 mg/kg (typically 600 mg) daily 1
• Pyrazinamide: 15-30 mg/kg daily (maximum 2g) 2
• Ethambutol: 15-25 mg/kg daily 1
• Pyridoxine (vitamin B6): 25-50 mg daily should be given with isoniazid to all persons at risk of neuropathy (pregnant women, breastfeeding infants, persons with HIV, diabetes, alcoholism, malnutrition, chronic renal failure, or advanced age) 1

Intermittent Dosing Options

• Twice-weekly dosing:

  • Isoniazid: 15 mg/kg (typically 900 mg) 1
  • Rifampin: 10 mg/kg (typically 600 mg) 1
  • Pyrazinamide: 50-70 mg/kg 2
  • Ethambutol: 50 mg/kg 1

• Thrice-weekly dosing (only for non-HIV patients at low risk of relapse):

  • Isoniazid: 15 mg/kg (typically 900 mg) 1
  • Rifampin: 10 mg/kg (typically 600 mg) 1
  • Pyrazinamide: See daily dosing table 1
  • Ethambutol: See daily dosing table 1

First-Line Drug Dosing for Children

Daily Dosing (Preferred Regimen)

• Isoniazid: 10-15 mg/kg daily 1
• Rifampin: 10-20 mg/kg daily 1
• Pyrazinamide: 35 (30-40) mg/kg daily 1
• Ethambutol: 20 (15-25) mg/kg daily 1

Intermittent Dosing Options

• Twice-weekly dosing:
  • Isoniazid: 20-30 mg/kg 1
  • Rifampin: 10-20 mg/kg 1
  • Pyrazinamide: 50 mg/kg 1
  • Ethambutol: 50 mg/kg 1

Second-Line Drug Dosing

Fluoroquinolones

• Levofloxacin: 500-1000 mg daily for adults 1
• Moxifloxacin: 400 mg daily for adults 1

Injectable Agents

• Streptomycin: 15 mg/kg daily (maximum 1g) for adults 1
• Amikacin/Kanamycin: 15 mg/kg daily for adults 1
• Capreomycin: 15 mg/kg daily for adults 1

Other Second-Line Drugs

• Cycloserine: 10-15 mg/kg total (usually 250-500 mg once or twice daily) for adults 1
• Ethionamide: 15-20 mg/kg total (usually 250-500 mg once or twice daily) for adults 1
• Para-aminosalicylic acid: 8-12 g total (usually 4000 mg 2-3 times daily) for adults 1

Important Clinical Considerations

• For obese patients (>20% above ideal body weight), dosing based on ideal body weight may be preferred for initial doses 1
• Therapeutic drug monitoring should be considered for obese patients 1
• Rifabutin dose may need adjustment when used with protease inhibitors or non-nucleoside reverse transcriptase inhibitors 1
• For patients with peripheral neuropathy, increase pyridoxine dose to 100 mg/day 1
• Patients with decreased renal function may require the 15 mg/kg dose of injectable agents to be given only 3 times weekly to allow for drug clearance 1
• Children with HIV infection and/or low body weight (4-7 kg) may require higher rifampin doses due to lower drug exposure and higher risk of unfavorable outcomes 3
• Ethambutol should be used with caution in children whose visual acuity cannot be monitored 1

Standard Treatment Regimen

• The established standard regimen consists of an initial phase (first 2 months) with daily rifampin, isoniazid, pyrazinamide, and ethambutol, followed by a continuation phase (next 4 months) with daily rifampin and isoniazid 4
• Ethambutol can be omitted in the initial phase for patients with a low risk of isoniazid resistance (less than 4% primary resistance in the community) 4, 5
• For TB meningitis and CNS tuberculosis, treatment should be extended to 12 months total 4, 5

By following these dosing recommendations and considering patient-specific factors, optimal treatment outcomes can be achieved while minimizing adverse effects in patients with drug-susceptible tuberculosis.