If there is no noticeable improvement in the TB lymphadenitis even after 6 months of treatment, then, based on clinical judgement of the treating physician, the continuation phase may be extended upto 10 months. These cases should also be investigated for DR-TB at the end of 6 months of treatment.
5.8 Treatment for extra-pulmonary TB patients
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All EP TB patients will receive the same treatment as pulmonary TB patients and the total duration of treatment too will remain the same, i.e., initial 2 months of intensive phase followed by 4 months of continuation phase (2HRZE/4 HR). For certain complicated/severe forms of EP TB a total of 12 months of treatment may be considered by the treating physicians, i.e., 2 months of IP (HRZE) followed by up to 10 months of CP (HR) to be decided at the end of 6 months of treatment. EP TB patients who do not improve at the end of 6 months must be investigated for drug resistant TB and should be referred to specialist physicians or tertiary care centres (CDC, CDH, Medical colleges and NIDCH) for further management.
The duration of treatment for TB meningitis is 12 months because of the uncertain penetration of the blood brain barrier by some anti-TB drugs. It is also recommended that all patients with TB meningitis and TB pericarditis, an initial adjuvant corticosteroid therapy with dexamethasone or prednisolone, tapered over 6-8 weeks, should be used. The drug most frequently used is prednisolone, in a dosage of 0.5 – 1 mg/kg daily, increased up to 2 mg/kg daily in the case of severely ill patients, for 4 weeks. The dose should then be gradually tapered down @ 2.5 - 5 mg every week over 4 to 8 weeks (1-2 months in total duration).
Alternatively, dexamethasone can be used as an adjuvant therapy for CNS disease. The recommended dosage is 0.1 - 0.2 mg/kg/day (depending on severity of the disease) for 2-4 weeks followed by gradual tapering of the dose @ 0.1mg/kg/week until it reaches a dosage of 0.1mg/kg/day (0.3 mg/kg per day in 1st week of tapering, 0.2 mg/kg per day in the 2nd week and 0.1 mg/kg per day in the 3rd week). This is followed by weekly tapering of oral dexamethasone @ 1 mg/week (4 mg/day, 3 mg/day, 2 mg/day and 1 mg/day, each for a period of 1 week). The total duration of this therapy is usually of 12 weeks.
Treatment of osteoarticular TB and spinal TB for treatment is 12 months with 2 (HRZE)/10 (HR). Pott's disease is a severe form of TB that should be treated on a priority basis because of the risk of neurological sequelae due to the chronic compression of the spinal nerves. In the absence of significant deformity and neurological deficit, most cases of spinal TB can be successfully treated with rest, back support bracing and anti-TB drugs. Surgery should be considered for patients with neurological deficit, an unstable spine lesion, and/or when they are not responding to therapy.
Monitoring response to extra pulmonary treatment:
For patients with extra pulmonary TB, clinical monitoring is the usual way of assessing the response to treatment