Presentation 0416 FINAL.pptx [Read-Only] · 4/14/2016 · Microsoft PowerPoint - Presentation 0416...
Transcript of Presentation 0416 FINAL.pptx [Read-Only] · 4/14/2016 · Microsoft PowerPoint - Presentation 0416...
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It’s Never Just TB –Juggling TB and Alcoholism
Nurse Case Management of the TB Patient April 14, 2016
NTNC MEMBERSHIP DRIVE – WEBINAR
National Tuberculosis Nurse Coalition
The mission of the NTNC is to advise and support the TB control officials of state, local, and territorial governments by providing, within NTCA, a coordinated nursing perspective on issues vital to the success of TB prevention and control programs.
NTNC Membership Opportunities
• Membership is tied to NTCA
Any member of the NTCA can select to be a member of the NTNC section if…
• Nursing background and education
• Current/previous position in TB nursing
• Interested in TB nurse case management
• Desire to be involved with a group of active individuals who share a professional identity
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Membership Information
• January is the time to renew your membership in NTCA and NTNC!
• Individual Membership is still just $55 per year and includes: Reduced registration for the annual National TB Conference
Reduced prices on NTCA/NTNC products, e.g., Comprehensive TB Nursing Manual
Participation in NTCA or NTNC Member Only events
Subscription to the e‐newsletter
New in 2015 and 2016
Expanded membership opportunities Institutional Program Membership (2015)
• TB controller and 4 others (Program must be directly funded by CDC co‐ag)
Local Institutional Program Membership (2015)• TB controller and 4 others (Programs not directly funded by CDC co‐ag)
Additional members to an institutional membership can join for only $25! (new in 2016)
Check with your TB controller to see if your program or health department has taken advantage of this
institutional membership!
Benefits of NTNC Membership
• Collective voice for TB Nurses
• Forum for exchange of ideas with other TB Nurses
• Presentations for members only
• Archived presentations for members only
• Professional home for nurses working in TB
• Networking with a great group of people!
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Join or Renew Now!
• To renew your NTCA/NTNC membership, or to join for the first time,
Go to http://tbcontrollers.org/ and complete the online application
Call the NTCA office and complete the application over the telephone – 678‐503‐0503
Question and Answer
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• Find the Q&A box on your screen
• Type in your question or comment and hit send to submit to the Moderator
• Questions will be answered AFTER the presentation, but you may submit them at any time.
TB and Alcohol Use Disorder Webinar
Cuyahoga County TB Program
MetroHealth Medical Center
Cleveland, Ohio
April 14, 2016
Charlie Bark, MDMedical Director
Katie Emanuel‐DeJoy, RNNursing Director
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Disclosures
• None
• No financial conflicts
Objectives
1. Describe what is known about the relationship between alcohol use disorder and the risk of tuberculosis.
2. Discuss the challenges in the management of tuberculosis in people with alcohol use disorder.
3. Review strategies to prevent tuberculosis in those with alcohol use disorder and latent tuberculosis infection.
4. Review TB Cases involving alcohol use disorder5. Review alternative TB regimens when treating
TB patients with alcohol use disorder
Objective 1
Describe what is known about the relationship between alcohol use disorder and the risk of
tuberculosis
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Alcohol and TB: The History
Alcohol and TB: The Science
Alcohol Res Health. 2010; 33(1‐2): 97–108.
Alcohol and TB: The Practical
• Alcoholic patients suffer from a disease where alcohol consumption is their priority, and judgement if often impaired
– TB treatment is usually not a priority
– Lack of buy‐in, lack of adherence
– Often concurrent liver disease and increased hepatotoxicity risk
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Alcohol Use Disorder (AUD)
• DSM 5
• AUD replaces “alcohol abuse” and “alcohol dependence”
Alcohol Use Disorder: Criteria
1. Recurrent drinking resulting in failure to fulfill role obligations2. Recurrent drinking in hazardous situations3. Continued drinking despite alcohol‐related social or interpersonal
problems4. Evidence of tolerance5. Evidence of alcohol withdrawal or use of alcohol for relief or
avoidance of withdrawal6. Drinking in larger amounts or over longer periods than intended7. Persistent desire or unsuccessful attempts to stop or reduce drinking8. Great deal of time spent obtaining, using, or recovering from alcohol9. Important activities given up or reduced because of drinking10. Continued drinking despite knowledge of physical or psychological
problems caused by alcohol11. Alcohol craving
AUD: Severity
• Mild: Two to three symptoms
• Moderate: Four to five symptoms
• Severe: Six or more symptoms
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Alcohol Use Disorder in the U.S.
JAMA Psychiatry. 2015;72(8):757‐766.
Alcohol use in the U.S.
In the past 30 days:
• 52% had at least 1 drink
• 23% binge drink
• 6% drink heavily
2011 US National Survey on Drug Use and Health
CDC Study: TB and Alcohol in the U.S.
• CDC Study of 207,307 TB patients
• 2007‐2012
Int J Tuberc Lung Dis. 2015;19:111‐9.
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CDC: TB and Alcohol in the U.S.Prevalence of Excess Alcohol Use
Int J Tuberc Lung Dis. 2015;19:111‐9.
CDC: TB and Alcohol in the U.S.Risk Factors
CDC: TB and Alcohol in the U.S.States
Int J Tuberc Lung Dis. 2015;19:111‐9.
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CDC: TB and Alcohol in the U.S.Time to Culture Conversion
Int J Tuberc Lung Dis. 2015;19:111‐9.
CDC: TB and Alcohol in the U.S.
• Excessive alcohol use is seen in about 15% of TB patients
• Time to culture conversion to negative is prolonged
• Rates of death and loss to follow‐up are significantly higher
Objective 2
Discuss the challenges in the management of tuberculosis in people with alcohol use
disorder
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Case 1: M.C.
• 53 y.o. man with R lung and pleural TB
• History of AUD: Drinks “6‐7 beers per day”, no known cirrhosis
• Could not remember when he became sick
• Sister found him “sick” and brought him to the hospital where he was diagnosed and started on TB treatment
Case 1: M.C.Treatment Course
• Discharged to Sister’s house, DOT continued
• 10 days later his Sister says he “disappeared”
• He has no cell phone, no address
• Next day presented to a local ED
Case 1: M.C.: Treatment Course Continued
• ED called, said he was being discharged to Sister
• He did not show‐up, could not be found for 2 weeks
• Then presented to Metro ED after a fall (due to alcohol intoxication) at a homeless shelter, dx’d with hip fracture
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Case 1: M.C.Treatment Course Continued
• Discharged to nursing facility, but soon left AMA
• Could not be found for 5 days ‐until he was located at a city homeless shelter
• Finally completed 6 months of treatment in 7 months (due to exceptional outreach efforts)
• Did not show for his 6 month post‐treatment follow‐up
Objective 3
Review strategies to prevent tuberculosis in those with alcohol use disorder and latent
tuberculosis infection.
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Case 1: C.B.
• C.B. is a 44 y.o. man with a history of “hepatitis” referred from a homeless shelter for a +PPD
• Reports drinking 6‐12 beers per day
• Exam has no TB findings, and CXR is normal
• Do you treat for LTBI?
Case 1: C.B.Poll
• Yes, I would treat LTBI
• No, I would not treat LTBI
To Treat or Not To Treat?
• Issues:
– Risk vs benefit
• Risk of Drug Induced Liver Injury (DILI)
• Benefit of preventing active TB
–Will he take the medication?
– How will you follow him?
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TB Hepatotoxicity Guidelines
Am J Respir Crit Care Med. 2006;174:935‐952.
TB Hepatotoxicity Guidelines: LTBI Pretreatment Evaluation
ATS TB Hepatotoxicity Guidelines
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Case 1: C.B.
• LFTs are normal
• Patient agrees to treatment –says he will cut down the drinking
• What regimen should we use?
LTBI Regimens: Poll
Which LTBI Regimen would you choose?
a) INH x 9 monthsb) INH x 6 monthsc) INH and Rifapentine x 12
weeksd) Rifampin x 4 months
Case 1: CBTreatment Options
• Rifampin vs INH‐Rifapentine
• INH‐Rifapentine = 3HP
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3HP PREVENT TB Trial
• 9H‐SAT vs 3HP‐DOT
• 2001‐2008
• Enrolled 8053 patientsN Engl J Med. 2011;365:2155‐66
3HP PREVENT TB Trial
• 3817 (~50%) reported using alcohol
• 255 reported abusing alcohol
• 194 reported having cirrhosis
• 196 had Hepatitis C
• 102 had Hepatitis B
N Engl J Med. 2011;365:2155‐66
3HP PREVENT TB Trial
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Monitoring for Hepatotoxicity during LTBI Treatment
TB Hepatotoxicity Guidelines
*anecdote Bhutanese Refugee
Objective 4
Review alternative TB regimens when treating TB patients with alcohol use
disorder
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Case 2: L.T.
• 64 y.o. Man with HepC, AUD, referred for abnormal CXR. RUL cavity with 4+ AFB smear, probe+ MTB
• HepC +: untreated, viral load = 2 million
• Drinks “a fifth” a day
– fifth of a gallon or 25 fluid ounces (757 mL)
• AST = 180, ALT=90, Normal Bili
Approach to Treatment
• TRANSFER?
Approach to Treatment
• Not treating is not an option
• Best to construct a regimen with TB as well as hepatology expertise input
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Less Hepatotoxic Regimens
• Treating without Pyrazinamide (PZA)
– INH/Rifampin/Ethambutol x 9 months
• Treating without INH and PZA
– Rifampin/Ethambutol/Fluoroquinolone
• Treating without INH/PZA/Rifampin
– Call 1‐800‐TBEXPERT
Monitoring for Hepatotoxicity during Active TB Treatment
Conclusions
• Alcohol Use is common in the U.S. and among TB patients
• Alcohol use disorder presents challenges to TB treatment: increasing side effects and decreasing adherence
• Always seek help when unsure
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Thank you!
Questions?
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It’s been a pleasure to provide this education to you all. Many thanks to our speakers, our moderator, our NTNC membership committee, and the staff at BlueSky for their hard work and dedication.
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