Lzd, Cs or Trd, H, Eto or Pto; rarely E, FQs
Peripheral neuropathy refers to damage to the nerves located outside of the central nervous system. This adverse effect is associated to several TB drugs but is commonly due to Lzd, Cs or Trd and H.
Peripheral neuropathy occurs most commonly in the lower extremities. Signs and symptoms include sensory disturbances (e.g. numbness, tingling, burning, pain, loss of temperature sensation), difficulty walking, weakness and decreased or absent deep tendon reflexes. At times, sensory changes may occur in upper extremities.
Linezolid-induced neuropathy is extremely painful and may be non-reversible.
1) Patient on DS-TB treatment
- To prevent isoniazid-induced peripheral neuropathy:
Administer pyridoxine PO to patients at risk (pregnant and breastfeeding women, neonates and breastfed infants, and patients with HIV infection, alcohol dependency, malnutrition, diabetes, chronic hepatic disease, and renal impairment) along with their TB treatment:
Neonate, child < 5 kg: 5 mg once daily
Child ≥ 5 kg and adult: 10 mg once daily
- If peripheral neuropathy develops:
Administer pyridoxine PO
Child < 12 years: 10 to 20 mg 2 times daily
Child ≥ 12 years: 50 mg 2 times daily
Adult: 50 mg 3 times daily
For pain management: ibuprofen or paracetamol.
2) Patient on DR-TB treatment
- To prevent peripheral neuropathy:
Administer pyridoxine PO:- Patient on H: all patients at risk, as for DS-TB.
- Patient on Cs or Trd, Lzd, Hh and Eto or Pto:
Neonate, child: 1 to 2 mg/kg (usual range in child: 10 to 50 mg) once daily
Adult: 100 mg once daily
- If peripheral neuropathy develops:
- Patient on Lzd: stop Lzd immediately. For mild symptoms not requiring analgesics, Lzd can be restarted at a lower dose once symptoms subside. For moderate or severe symptoms, stop Lzd permanently. Consider additional TB drugs to reinforce the therapeutic regimen.
- Patient on Cs or Trd or Hh: stop these drugs. If they are essential to the regimen, they may be re-introduced once symptoms subside.
Other contributing causes should be addressed (e.g. diabetes or malnutrition).
Administer pyridoxine PO: 100 mg daily in adults until symptoms resolve.
For pain management: ibuprofen or paracetamol.
Physiotherapy may be of benefit.
If these measures are insufficient, treat as chronic neuropathic pain, but avoid tricyclic antidepressants in patients on Lzd (risk of serotonin syndrome).
Do not use carbamazepine (strong CYP450 inducer) in patients on Bdq or Dlm.