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A 62-Dose, 6-Month Therapy for Pulmonary and Extrapulmonary Tuberculosis: A Twice-Weekly, Directly Observed, and Cost-Effective Regimen

David L. Cohn, MD; Barbara J. Catlin, RN; Karen L. Peterson, MD; Franklyn N. Judson, MD; and John A. Sbarbaro, MD, MPH
[+] Article, Author, and Disclosure Information

Requests for Reprints: David L. Cohn, MD, Denver Disease Control Service, 605 Bannock Street, Denver, CO 80204.

Current Author Addresses: Drs. Cohn and Judson and Mrs. Catlin: Denver Disease Control Service, 605 Bannock Street, Denver, CO 80204.

Dr. Peterson: Cambridge Hospital, 1493 Cambridge Street, Cambridge, MA 02139.

Dr. Sbarbaro: University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262.

©1990 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1990;112(6):407-415. doi:10.7326/0003-4819-76-3-112-6-407
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Study Objective: To evaluate the efficacy and toxicity of a 62-dose, four-drug, 6-month, and directly observed regimen for treatment of pulmonary and extrapulmonary tuberculosis.

Design: An open, nonblinded clinical trial, with intended follow-up of patients for 36 months after the completion of therapy.

Setting: A metropolitan tuberculosis clinic in a public health department.

Patients: From March 1981 through April 1989, we enrolled 160 patients with suspected or known tuberculosis; 35 of these patients were excluded from the analysis.

Interventions: Isoniazid, rifampin, pyrazinamide, and streptomycin were administered daily for 2 weeks; these drugs were then given in higher doses twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 18 weeks. A total of 62 doses were administered, and all therapy was directly observed by a nurse or an outreach worker.

Measurements and Main Results: Of the 125 evaluable patients, 101 (81%) had pulmonary tuberculosis, 7 (6%) had both pulmonary and extrapulmonary involvement, and 17 (13%) had extrapulmonary disease only. Seventy-one (57%) patients had a history of recent alcoholism. There were two relapses (1.6% ± 2.2%), occurring 6 and 56 months after the completion of therapy. The time at which sputum samples became culture negative in pulmonary patients ranged from 1 to 19 weeks (median, 4.6 weeks); 40% ± 9.6% of patients were culture-negative after 4 weeks of therapy, 75% ± 8.5% after 8 weeks, 94% ± 4.7% after 12 weeks, 97% ± 3.3% after 16 weeks, and 100% after 20 weeks. Adverse drug reactions included hyperuricemia (> 178 µmol/L [3 mg/dL] above normal) secondary to pyrazinamide in 80 patients (64%), twofold or greater elevations of aspartate aminotransferase in 21 patients (17%), 1.5-fold or greater elevations of alkaline phosphatase in 33 patients (27%), cutaneous abnormalities in 8 patients (6%), nausea in five patients (4%), and dizziness in 1 patient (1%).

Conclusions: This 62-dose, largely twice-weekly tuberculosis treatment regimen is efficacious and relatively nontoxic and is especially useful for patients in whom directly observed therapy is indicated.





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