9.4 Special situations

9.4.1 Women (pregnant or breastfeeding or of childbearing age)

Pregnant or breastfeeding women

• All TB drugs used in conventional regimens, except rifabutin, can be used during pregnancy and breastfeeding [1] Citation 1. World Health Organization. Guidelines for treatment of drug-susceptible tuberculosis and patient care – Annex 6: Essential first line antituberculosis drugs. 2017 update.
  https://apps.who.int/iris/bitstream/handle/10665/255052/9789241550000-eng.pdf .
• Isoniazid may cause peripheral neuropathy due to vitamin B₆ (pyridoxine) deficiency:
  • Pregnant and breastfeeding women should receive pyridoxine PO (10 mg once daily) throughout the course of TB treatment.
  • Breast-fed neonates or infants should receive pyridoxine PO (5 mg once daily).
• Rifampicin may cause clotting disorders due to increased vitamin K (phytomenadione) metabolism:
  • Women in late pregnancy on rifampicin (or rifabutin) should receive phytomenadione PO (10 mg once daily) for 2 weeks prior to expected date of delivery.
  • Neonates should also receive phytomenadione IM at birth (1 mg single dose) to prevent haemorrhagic disease of the newborn.
• Alternative regimens containing rifapentine, moxifloxacin [2] Citation 2. Wendy Carr, Ekaterina Kurbatova, et al. Interim Guidance: 4-Month Rifapentine-Moxifloxacin Regimen for the Treatment of Drug-Susceptible Pulmonary Tuberculosis. Morbidity and Mortality Weekly Report. Vol. 71 / No. 8 February 25, 2022.
  https://doi.org/10.15585/mmwr.mm7108a1 and/or ethionamide cannot be used to treat DS-TB in pregnant and breastfeeding women.

Women of childbearing age

Women on contraception should use an intra-uterine device or a progestogen-only injectable throughout the courses of TB treatment, as rifamycins reduce the effectiveness of implants and oral contraceptives.

9.4.2 Malnutrition or risk of malnutrition

• For patients with malnutrition, therapeutic feeding should be initiated.
• For children with severe acute malnutrition, a 6-month regimen is preferred over a 4-month regimen until more data on the efficacy of the 4-month regimen in these patients become available.
• For at-risk populations, such as children, pregnant and breastfeeding women and the elderly, nutritional supplementation with a standard food package or ready-to-use food may be considered during the first 2 months of treatment.

9.4.3 Diabetes

TB can impair glycaemic control in patients with diabetes [3] Citation 3. World Health Organization & International Union against Tuberculosis and Lung Disease. (‎2011)‎. Collaborative framework for care and control of tuberculosis and diabetes. World Health Organization. https://iris.who.int/bitstream/handle/10665/44698/9789241502252_eng.pdf?sequence=1 . It is necessary to increase blood glucose monitoring in these patients.

TB drugs can exacerbate complications of diabetes (e.g. peripheral neuropathy). Avoid prescribing ethambutol in patients with pre-existing diabetic retinopathy.

Rifampicin can reduce the effect of sulfonylureas (e.g. glibenclamide, gliclazide). In contrast, first-line TB drugs have no interactions with metformin. 

If diabetes is diagnosed, treat and monitor according to standard protocols.

At the end of TB treatment, it is recommended to schedule a specialist consultation for a complete evaluation and, if necessary, adjust antidiabetic treatment.

9.4.4 Renal insufficiency

In patients with renal insufficiency, creatinine clearance should be calculated. If it is less than 30 ml/minute, doses of certain TB drugs should be adjusted.
For the formula to estimate the creatinine clearance and dose adjustments in renal insufficiency, see Appendix 12.