11.4 Special situations

11.4.1 Women (pregnant or breastfeeding or of childbearing age)

Pregnant or breastfeeding women

• There is no data on the safety of the Hr-TB regimens in pregnant or breastfeeding women. WHO recommends the regimen 6(HRZE) [1] Citation 1. World Health Organization. WHO operational handbook on tuberculosis. Module 4: treatment - drug-resistant tuberculosis treatment, 2022 update. Geneva; 2022.
  https://www.who.int/publications/i/item/9789240006997 .

However, there is no absolute contraindication to the use of levofloxacin. In patients with severe TB (e.g. extensive or bilateral lung damage or cavities, miliary TB or TB of the central nervous system) the standard regimen may be considered.

• For prevention of peripheral neuropathy due to isoniazid and clotting disorders due to rifampicin, see Chapter 9.

Women of childbearing age

• Women on contraception should use an intra-uterine device or a progestogen-only injectable throughout the course of TB treatment, as rifampicin reduces the effectiveness of implants and oral contraceptives.
• For women not on contraception, a pregnancy test should be performed prior to starting Hr-TB treatment and, if necessary, repeated during treatment. An effective contraception method (see above) should be offered prior to starting treatment.

11.4.2 Malnutrition or risk of malnutrition

See Chapter 9.

11.4.3 Diabetes

TB can impair glycaemic control in patients with diabetes [2] Citation 2. 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 therefore necessary to increase blood glucose monitoring in these patients.

TB drugs may exacerbate complications of diabetes (e.g. peripheral neuropathy). Avoid prescribing ethambutol and linezolid 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, adjustment of antidiabetic treatment.

11.4.4 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 creatinine clearance and dose adjustments in renal insufficiency, see Appendix 12.