10.8 Management of patients whose treatment failed and palliative care

When it has been determined a patient is failing therapy for DR-TB, the first priority is to design a new regimen using the principles described in Sections 10.1 to Section 10.3. The new regimen should contain at least two new effective drugs.

The employment of newly developed TB drugs available for compassionate use (Appendix 11) is encouraged. For some of these drugs (delamanid), approval is expect in 2013.

When no therapeutic option or new regimen is possible, the patient can be continued on an anti-TB regimen that is reasonably tolerated (and if the patient desires) or the regimen can be completely stopped. The decision to stop therapy should be made after careful evaluation and consultation with the patient, the family and the MDR-TB treatment team.

Palliative/supportive care should be continued. Supportive measures for minimizing suffering due to the disease or the therapy should be implemented according to the patient needs.
Supportive measures may include:
– Relief of respiratory symptoms: oxygen should be used to alleviate shortness of breath; corticosteroids (prednisolone) are beneficial in severe respiratory insufficiency; codeine helps control cough.
– Identification, assessment and treatment of pain: according to the standard recommendations (non opioids/mild opioids/strong opioids adapted to the level of pain).
– All necessary ancillary medications needed should be used.
– Patients with poor nutritional status should receive nutritional support.
– In debilitated patients, important measures for making patients comfortable and preventing complications must be taken. Regular scheduled movement of the bedridden patients prevents bedsores. Bathing and oral care assistance keeps patients clean and comfortable, while preventing skin infections.
– Disorders such as anxiety or depression due to prolonged sickness, separation from family, difficult living conditions, etc. should be addressed when present. The patient as well as the family may need support.
– Potential social problems should also be addressed. When necessary, hospice-like care should be offered to families who want to keep the patient at home. Inpatient end-of-life care should be available to those for whom home care is not available.

Note: the above palliative/supportive measures should be implemented to all DR-TB patients if indicated whether or not they are failing treatment. Some measures may even need to be continued after a patient’s TB has cured, but the patient still remains with significant respiratory damage.