Haematologic disorders

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    Lzd, R, P, Rfb, E
     

    Most TB drugs can cause hematologic disorders that may involve any blood cells (red cells, white cells, platelets). However, the TB drugs most involved are Lzd and rifamycins.

     

    Severity grade

    in adults (a) Citation a. Adapted from NIAID Division of Microbiology and Infectious Diseases, severity scale, Nov-2007.

    Anaemia

    Neutropenia

    Thrombocytopenia

    Mild

    10.5 - 9.5 g/dl

    1500 - 1000/mm³

    100,000 - 75,000/mm³

    Moderate

    < 9.5 - 8.0 g/dl

    < 1000 - 750/mm³

    < 75,000 - 50,000/mm³

    Severe

    < 8.0 - 6.5 g/dl

    < 750 - 500/mm³

    < 50,000 - 20,000/mm³

    Life-threatening

    < 6.5 g/dl

    < 500/mm³

    < 20,000/mm³

    1) Patient on DS-TB treatment

    Rifamycins can cause potentially life-threatening thrombocytopenia. This is more common when used intermittently.
    Clinical features may include minor haemorrhage (e.g. epistaxis) or severe haemorrhage and thrombocytopenic purpura.

     

    Measure platelets when thrombocytopenia is suspected:

    • Moderate thrombocytopenia: stop the rifamycin and monitor platelets weekly until > 75,000/mm3.
    • Severe thrombocytopenia: stop all TB drugs. Hospitalise. Treat shock or severe haemorrhage.

     

    In any event rifamycins should not be reintroduced.

    2) Patient on DR-TB treatment

    Lzd may cause anaemia, neutropenia and/or thrombocytopenia.

     

    Toxicity

    Management

    Mild to moderate

     
    • In all cases:
      • Monitor carefully.
      • Consider reduction of dose of Lzd (e.g. 300 mg once daily or 600 mg 3 times weekly in adults).
    • For moderate anaemia: consider adding erythropoietin (EPO).
    • For moderate neutropenia:
      • Stop Lzd.
      • Restart at reduced dose once toxicity has decreased to "mild".

    Severe

     
    • In all cases:
      • Stop Lzd and monitor carefully.
      • If Lzd is essential to the regimen, restart at reduced dose once toxicity has decreased to "mild".
    • For severe anaemia: consider adding EPO.

    Life-threatening

     
    • Stop Lzd and monitor carefully.
    • Hospitalise.
    • Perform blood transfusion
    • If Lzd is essential to the regimen consider restarting at reduced dose once toxicity has decreased to "mild".

     

     

    • (a)Adapted from NIAID Division of Microbiology and Infectious Diseases, severity scale, Nov-2007.
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