HEATHER BUSIG, RN, BSN

COMPLEX MEDICATION MANAGEMENT IN A CLIENT WITH PRE-XDR TB

FINDING THE BEST MEDICATIONS FOR SOMEBODY WITH MDR TB IS COMPLICATED! FACTORS TO CONSIDER INCLUDE:

1. Which antibiotics the organism is susceptible to

2. How well the client tolerates the medications

3. How well the drug works to kill TB

4. Drug interactions with other medications the client is taking

5. The ability of the health department and local pharmacy to obtain the antibiotics

6. What the local MD is willing to do to try an antibiotic (IRB?)

7. Whether or not the client is willing to try something with potential side effects he/she doesn’t want

8. The cost of the antibiotics and coverage by the client’s insurance

As you can imagine, it can be extremely complicated.

THE BEGINNING… • X is an elderly Hmong woman who had been in the US for quite

some time.

• She has very little family and social support, and a very complex family situation

• X was diagnosed with active TB in August, 2013

• Because we have a fair amount of resistant TB in Wisconsin (and especially in Marathon County), the decision was made to wait to treat her TB until the resistance pattern was known. Molecular results returned quite quickly.

• In her culture, she believed that she was worthless, lower than a dog. She was unable to even speak up for herself.

Molecular resistance results received 8/21/2013:

•Rifampin: Mutation=resistant

•Isoniazid: Mutation=resistant

•Ethambutol: Mutation=resistant

•Pyrazinamide: Mutation=effect unknown. Cannot rule out resistance

•Amikacin: Mutation=effect unknown. Cannot rule out resistance

•Capreomycin: Mutation=effect unknown. Cannot rule out resistance

Molecular resistance results 8/28/2013:

Results of 1st and 2nd line susceptiblities 10/3/13

Susceptibilities to 3rd line medications

•Azithromycin: susceptible

•Linezolid: susceptible

•Moxifloxacin: susceptible

•Clofazimine: susceptible

•Cycloserine: susceptible

•Clarithromycin: susceptible

DOT BEGINS AT HOME… • November 19, 2013 our client was discharged from the hospital and

began DOT on the following medication regimen:

Tolerance issues with TB medications • NAUSEA AND VOMITING--Especially with the PAS. It got to the point

that she would start to gag at the site of the packets.

• SEVERE DEPRESSION—Caused by her lack of social and family support as well as from her isolation as well as a side effect from the medications

• BODY ACHES INCLUDING BACK PAIN

• INSOMNIA

• FATIGUE

• WEIGHT LOSS—from the nausea and vomiting and from her lack of appetite (medication side effect)

Sample of our weekly assessment form:

Our client was getting sicker and sicker •Therapeutic drug levels were drawn on 12/9/2013

•Cycloserine: 88.4mcg/mL (therapeutic range 20-35 mcg/mL)

•Ethionamide: 2.6 mcg/mL (therapeutic range 1-5 mcg/mL)

•Linezolid: 16.94 mcg/mL (therapeutic range 12-26 mcg/mL)

•Moxifloxacin: 6.37 mcg/mL (therapeutic range 3-5 mcg/mL)

•PAS: 79.2 mcg/mL (therapeutic range 10-60 mcg/mL)

CHANGES WERE MADE TO HER MEDICATIONS • By Late April, her TB medication regimen looked like this:

HOLDING PATTERN •This was when our client started doing better.

•Appetite began to improve

•She was released from isolation in March 2014

•We had caregivers in place regularly and she was able to get social interaction

•There were still minor adjustments being made to her medications, but overall things were going well and we were finally heading in the right direction.

SMALLER BUMPS IN THE PAST YEAR OR SO • She began having issues tolerating the Ethionamide. It was stopped

while she took a first round of bedaquiline and a second round of bedaquiline. We tried to restart it this summer, but just didn’t tolerate it well.

• Clofazamine was one of the drugs that the isolate was susceptible to, but the client did not want the possible side effect of skin darkening and the MD did not want to go through IRB to be able to use it.

• In August, we drew TDLs (drug levels) at 2 hours and 6 hours after her medications were taken, and they sat in a FedEx warehouse for 3 days before they went to National Jewish Hospital in Denver. They were useless by then.

Sirturo (Bedaquiline or BDQ) issues • Long half life. Stays in system for approximately 4 months after

complete the 6 month course of treatment

• Has a 2 week loading dose followed by three times/week dosing given over a total of 24 weeks.

• My client is on her 3rd round of BDQ as she needs to be on a minimum of 4 drugs the entire length of treatment. Most people only get one round of it. A few have had 2 rounds of BDQ. Even fewer have had more than 2 rounds

• There was no way to check drug levels. Now there is, but there is not yet agreement as to what the levels mean and what to do about them.

• It costs approximately $30,000 for 6 months of treatment, which averages out to a little more than $150/pill.

What do you do if your client drops one tab of BDQ on the floor?

SYSTEMS ISSUES—CYCLOSERINE IN THE NEWS

This was from an article published in the NY times on 9/20/15:

CYCLOSERINE IN THE NEWS

HOW IS SHE DOING NOW?

•Symptomatically, she is doing great.

•Continue to consult with Mayo Clinic TB center re: future recommendations

•Considering surgery to remove an area that is not healing after almost 2 years of medications

•She has gained back all of the weight she lost in the early part of treatment

•She is no longer depressed and is even advocating for herself.

QUESTIONS?

THANK YOU