I. Familiar with the clinical manifestations of adverse reactions to anti-tuberculosis drugs, especially the early clinical manifestations
1, peripheral neuritis: in the past, mostly caused by INH, now INH using conventional doses do not occur or rarely occur peripheral neuritis. When 12.5 to 15.6 mg/kg per day, the incidence of peripheral neuritis is 10% to 15%, seen in slow acetylating individuals. Clinical manifestations are terminal sensory deficits.
2. Central nervous system ADR: It can be seen in people who use INH, quinolones, aminoglycosides in high doses or with pre-existing neurological underlying diseases, mainly manifesting as excitement, euphoria, memory loss, inattention, headache, vertigo, insomnia, drowsiness, hallucinations, tremor, convulsions, extravertebral reactions, etc. In severe cases, grand mal seizures, even psychosis, disorders of consciousness, etc.
3, histamine accumulation in the body: seen in high doses of INH, can cause arterial dilation, capillary permeability, plasma exudation, skin flushing, rash, smooth muscle spasm; and may have headache, dizziness, nausea, vomiting, abdominal pain, diarrhea, eye conjunctival congestion; and even breathing difficulties, blood pressure, heart rate accelerated. When taking INH and consuming fish with high histamine content, the toxic reaction of histamine accumulation is easily induced.
4. Drug-related hepatitis: with clinical manifestations of general hepatitis and abnormal liver function tests. The incidence is about 8%-30%. Mild manifestations include lack of food and drink, nausea, vomiting, discomfort in the liver area, and abnormal liver function tests can be found. Severe cases occur in patients with underlying liver disease, older age, and poor general nutritional status, with tests indicating significantly elevated bilirubin and alanine transferase (ALT) and clinical symptoms such as nausea, vomiting, high fever, jaundice, hepatomegaly, and even liver failure. The probability of jaundice with RFP is almost 12 times higher than the total of jaundice with all other anti-tuberculosis drugs.
5, gastrointestinal reactions: most common in PAS, PZA, followed by RFP, other drugs are relatively rare. The manifestation is not thinking about eating and drinking, nausea, vomiting, abdominal distension, abdominal pain, etc., need to check to exclude liver injury factors.
6, skin damage: manifested as pruritus, reddish-brown skin, rash, etc., mostly seen in persistent type I allergic reactions. Exfoliative dermatitis and maculopapular dermatitis belong to type IV allergic reactions. Clofazimine users 75% to 100% of patients can discolor the skin and conjunctiva, the skin first slightly red, developing into russet, leprosy damage site coloring deeper, can be purple-red, greenish gray or even black, coloring depth varies from person to person, the dose is large, the drug is used for a long time, coloring deep, urine, sputum and sweat can also be red, gradually disappear after discontinuation of the drug.
7.Joint and muscle pain: mostly occurs in patients who use PZA and levofloxacin.
8, hematocrit: including white blood cells, red blood cells, platelets single or multi-lineage reduction, often appear in Rft or RFP chemotherapy, chemotherapy should be regular blood tests during the period, need to check to exclude blood and hematopoietic system-related diseases.
9, vision visual abnormalities: manifested as eye discomfort, lacrimation, photophobia, visual abnormalities, etc.. Often appear in EMB treatment.
10.Auditory nerve disorder: mostly seen in those who use aminoglycoside antibiotics. Vestibular nerve dysfunction manifests as dizziness, vision loss, nystagmus, vertigo, nausea, vomiting and ataxia; cochlear auditory nerve injury manifests as tinnitus, hearing loss and permanent deafness.
11, neuromuscular junction blocking manifestations: seen in high doses of aminoglycoside antibiotics, which can lead to respiratory depression, myasthenia gravis, paralysis, etc.
12, hyperuricemia: mainly seen in patients using PZA, a few seen in patients using EMB and high protein diet. It often causes gout attacks in patients with existing gout; when the blood uric acid value is close to 2 times the upper limit value, it can cause urate crystals causing kidney damage.
13, nephrotoxicity: usually manifested as frequent urination, oliguria, crystalluria, cloudy urine, proteinuria, tubular urine, hematuria, facial edema and other manifestations of nephritis, which can lead to reduced renal function and even azotemia and renal failure in severe cases. Among them, ciprofloxacin, ofloxacin, norfloxacin and rofloxacin have more reports of hematuria, and the proportion of cases of renal failure of pazufloxacin is relatively high.
14, clinical manifestations of allergic reactions: rapid type I allergic reactions can be manifested as anaphylaxis and respiratory angioneurotic edema dyspnea; persistent type I allergic reactions can be manifested as drug fever, drug rash, polymorphic erythema, photosensitivity dermatitis; elevated eosinophils or (and) IgE antibodies can be detected in type I allergic reactions. Type II allergic reactions may manifest as destruction of blood cells, and elevated IgG or (and) IgM may be detected, while total complement levels are often not elevated; Type III allergic reactions often manifest as liver, kidney and other organ damage, and elevated IgG or (and) IgM or (and) IgA may be detected, while total complement levels are elevated; Type IV allergic reactions mainly manifest as exfoliative dermatitis and herpetolytic dermatitis, and abnormal elevations of T Lymphocytes are abnormally elevated.
15, liver injury in immunocompromised or autoimmune deficient people: mainly manifested as biliary hepatitis.
Second, improve the content of medical history taking
Before using anti-tuberculosis drugs, patients should be thoroughly questioned about their personal history, past history, underlying diseases, especially relevant systemic diseases that may affect liver, kidney and blood functions. This includes.
(1) dietary habits.
(2) History of alcohol consumption.
(3) History of all types of hepatitis, especially hepatitis B and C, and their potential infection.
(4) History of bile duct disease.
(5) History of malnutrition-related diseases.
(6) History of endocrine and metabolic disorders.
(7) History of exposure to and onset of parasites that cause liver lesions.
(8) History of poisoning.
(9) History of medication ADR.
(10) History of allergies and family history of allergic diseases.
(11) History of constipation.
(12) History of renal disease.
(13) history of hematologic disease
(14) History of gastrointestinal disease
(15) history of neuropsychiatric disorders
(16) History of skin disease.
(17) History of cardiovascular disease and respiratory disease other than tuberculosis
(18) Whether currently taking medications for other diseases, etc.
Third, improve the laboratory test items, improve the laboratory test conditions and improve the quality of testing
Only blood, urine, stool and liver and kidney function, imaging is not enough, should improve the liver, kidney, nutrition, metabolism and other basic diseases and allergic diseases related to the examination.
IV. Diagnosis, classification and severity of ADR
1. Diagnosis of ADR: Judgment should be made based on the clinical manifestations of ADR, medication history and possible ADR of the drugs used, past history, laboratory tests and other data analysis, which is often difficult in clinical practice and requires the formation of guidelines or expert consensus.
2, the severity of ADR: generally divided into 3 categories.
(1) Mild: symptoms are mild and generally do not require special treatment or discontinuation of medication.
(2) Moderate: more pronounced symptoms, with some damage to organs and functions, requiring therapeutic management and/or discontinuation of medication.
(3) severe: the disease is serious, can cause significant disability to organs and functions, and even life-threatening, requiring hospitalization, and some should be rescued in time. In practice, the current taxonomy lacks quantifiable objective criteria and varies greatly in subjective judgments, again requiring specific quantifiable objective criteria to be standardized through guidelines or expert consensus.