Key points
Health care providers should advise patients being treated for latent tuberculosis (TB) infection or TB disease to report any signs and symptoms of adverse drug reactions. Consult TB medical experts for severe adverse reactions.
Overview
Adverse reactions to anti-tuberculosis (TB) drugs are relatively rare, but for certain patients, they can be severe.
Mild adverse effects can usually be managed by adjusting the timing of the medications, increasing fluids, advising patients to take medications with food, or managing mild symptoms with other medications.
Severe adverse reactions may require adjustments in treatment regimens and consultation with TB experts. State TB programs and the TB Centers of Excellence for Training, Education, and Medical Consultation can provide assistance and support for health care providers.
Common adverse reactions include:
- Gastrointestinal problems
- Hepatitis
- Rash
- Fever
Consult CDC guidelines, drug package inserts, and other authoritative medical sources for additional information.
Patient education
Health care providers should advise patients to report any signs and symptoms of adverse drug reactions, including:
- Unexplained loss of appetite, nausea or vomiting, brown urine, or jaundice (yellowing of skin or eyes)
- Persistent tingling, numbness, or burning of hands or feet
- Persistent weakness, fatigue, fever, or abdominal tenderness
- Easy bruising or bleeding
- Blurred vision or changed vision
- Rash
If the symptoms indicate adverse reactions, instruct the patient to stop the medication, and ask the patient to come to the clinic for relevant laboratory testing.
Possible adverse effects
| Caused by | Adverse Reaction | Signs and Symptoms | Significance of Reaction |
|---|---|---|---|
| Any drug | Allergic | Skin rash | Might be serious or minor |
| Ethambutol | Eye damage | • Blurred or changed vision • Changed color vision |
Serious |
| Isonaizid Pyrazinamide Rifampin Rifapentine |
Hepatic toxicity | • Abdominal pain • Abnormal liver function test results • Brown urine or light-colored stool • Fatigue • Fever for 3 or more days • Flu-like symptoms • Lack of appetite • Nausea • Vomiting • Yellow skin or eyes |
Serious |
| Isoniazid | Nervous system damage | • Dizziness • Tingling or numbness around the mouth |
Serious |
| Peripheral neuropathy | • Tingling sensation, numbness, or pain in hands and feeta | Serious | |
| Pyrazinamide | Stomach upset | • Stomach upset • Vomiting • Lack of appetite |
Might be serious or minor |
| Gout | • Abnormal uric acid levelb • Joint aches |
Serious | |
| Rifampin or Rifapentine | Bleeding problems (due to low platelets) | • Easy bruising • Slow blood clotting |
Serious |
| Discoloration of body fluids | • Orange urine, sweat, or tears • Permanently stained soft contact lenses |
Minor | |
| Drug interactions | Interferes with many medications, such as: • Birth control pills or implants, • Blood thinners, • Some HIV medicines, and • Methadone |
Might be serious or minor | |
| Rifabutin | Bone marrow suppression | • Leukopenia • Neutropenia • Anterior uveitis |
Serious |
a Pyridoxine (vitamin B6), 25–50 mg/day, is given with isonaizid to all persons at risk of neuropathy (e.g., pregnant persons; breastfeeding infants; persons with HIV; patients with diabetes, alcoholism, malnutrition, or chronic renal failure; or patients with advanced age). For patients with peripheral neuropathy, experts recommend increasing pyridoxine dose to 100 mg/day.
b Asymptomatic elevated uric acid levels are expected with pyrazinamide treatment. Acute gouty arthritis, which is rare without preexisting gout, is a contraindication for pyrazinamide use.
Drug-drug interactions
Patients should provide a list of current medications to health care providers to avoid drug interactions. Consult CDC guidelines, drug package inserts, and other authoritative medical sources for information about drug-drug interactions.
Some interactions to note:
Isoniazid increases blood levels of phenytoin (Dilantin) and disulfiram (Antabuse).
Rifampin and rifapentine decrease blood levels of many drugs including oral contraceptives, warfarin and some other anticoagulants ("blood thinners"), sulfonylureas (used for diabetes), and methadone. Health care providers should advise patients using hormonal contraceptives to consider an alternative method of contraception (e.g., a barrier method).
Rifampin and rifapentine are contraindicated in people with HIV being treated with most nonnucleoside reverse transcriptase inhibitors (NNRTIs), long-acting injectable antiretrovirals including cabotegravir and lencapavir, and some integrase inhibitors. For some combinations, dose adjustment and close monitoring can be used to manage drug interactions.
Patient monitoring
Obtaining a detailed and accurate medical history and updating information at frequent intervals will identify persons who require close monitoring during TB treatment.
The type and frequency of monitoring depends on the drugs used and the patient's risk for adverse reactions (e.g., age or alcohol use). At a minimum, health care providers should conduct monthly examinations and ask patients about any side effects from medication.