DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS)

TUBERCULOSIS (TB)
The available anti-TB drugs are:
• First Line anti-TB drugs: Rifampicin (R), Isoniazid (H), Ethambutol (E),
Pyrazinamide (Z), and Streptomycin (S)
• Second line anti-TB drugs: Levofloxacin (Lfx), Moxifloxacin (Mfx), Kanamycin
(Km), Capreomycin (Cm), Prothionamide (Pto), Cycloserine (Cs), Linezolid (Lzd),
Clofazimine (Cfz), Bedaquiline (Bdq), Para-aminosalicylic Acid (PAS) and
Imipenem (Imp). These drugs will only be used in certified PMDT centers.

Anti-TB drugs in fixed-dose combination (FDC) preparation.

• Adult FDC tablet: Contains isoniazid 75 mg and rifampicin 150mg, +/-
pyrazinamide 400 mg, +/-ethambutol 275 mg per tablet.
• Pediatric FDC dispersible tablet: Contains isoniazid 50 mg and rifampicin 75 mg,
+/- pyrazinamide 150 mg per tablet. Give the entire daily dose once a day.

Single-drug formulations (SDF) are still recommended for the following situations:
adverse reactions or at risk for adverse reactions; co-morbid conditions requiring
dose adjustments (especially liver, kidney diseases); or expected to have
significant drug interactions. However, local availability of SDFs is poor.

A. CATEGORY I

Etiology:
Pulmonary TB, New (no treatment or had undergone previous treatment for less
than a month; whether bacteriologically confirmed or clinically diagnosed)
Miliary TB without dissemination or with dissemination not involving meningitis,
bones, joints
Extrapulmonary TB (EPTB), New (whether bacteriologically confirmed or clinically
diagnosed) EXCEPT CNS, bones, joints

Preferred Regimen:
PEDIATRICS (<15Y):
Intensive phase (2 mos. HRZE) Continuation phase
BODY
(No. of tablets) (4 mos. HR)
WEIGHT
HRZ E (100 mg) HR
4-7 kg 1 1 1
8 – 11 kg 2 2 2
12 – 15 kg 3 3 3
16-24 kg 4 4 4
25 + kg Adult dose and preparations

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ADULTS:
Intensive phase (2 mos. HRZE) Continuation phase
BODY WEIGHT (No. of tablets) (4 mos. HR)
HRZE HR
30 - 37 kg 2 2
38 – 54 kg 3 3
55 – 70 kg 4 4
> 70 kg 5 5

Drug Dosage per kg body weight (if using single-drug formulations)

PEDIATRICS ADULTS
ANTI-TB Drug Dose (mg/kg Max dose/d Dose (mg/kg Max
BW) (mg) BW) dose/d(mg)
Isoniazid 10 (10 – 15) 300 5 (4 – 6) 400
Rifampicin 15 (10 – 20) 600 10 (8 – 12) 600
Pyrazinamide 30 (20 – 40) 2,000 25 (20 – 30) 2,000
Ethambutol 20 (15 – 25) 1,200 15 (15 – 20) 1,200

Comments:
ALL children being treated for TB should be weighed at least once every month to
allow for adjustment of dosage(s). All patients should be weighed monthly for
possible dose adjustments.

Anti-TB treatment shall be done through a patient-centered, Directly-Observed

Treatment (DOT) to foster adherence. Anti-TB treatment regimen shall be based
on anatomical site and bacteriologic status including drug resistance and history
of prior treatment, as well as the presence of co-morbid conditions.

A patient’s anti-TB regimen shall be comprised of at least four (4) first-line drugs.
Fixed dose combination (FDC) should be used even for children. Single drug
formulation should be used for specific subsets of patients such as those with
hypersensitivity reactions to rifampicin and other anti-TB drugs: drug reactions;
hepatic or renal impairment.

Refer to Table below on Summary of treatment regimens for EPTB.

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B. CATEGORY IA

Etiology: Extra-pulmonary TB (EPTB), New: CNS, bones or joints

Preferred Regimen:
PEDIATRICS (<15Y):
Intensive phase (2 mos. HRZE) Continuation phase
BODY WEIGHT (No. of tablets) (4 mos. HR)
HRZ E (100 mg) HR
4 - 7 kg 1 1 1
8 – 11 kg 2 2 2
12 – 15 kg 3 3 3
16 - 24 kg 4 4 4
25 + kg Adult dose and preparations

ADULTS:
Intensive phase (2 mos. HRZE) Continuation phase
BODY WEIGHT (No. of tablets) (4 mos. HR)
HRZE HR
30 - 37 kg 2 2
38 – 54 kg 3 3
55 – 70 kg 4 4
> 70 kg 5 5

Comments:
Referral to relevant specialties is recommended for EPTB. Use of corticosteroids
as adjunctive therapy is recommended ONLY for patients with TB meningitis
and/or TB pericarditis.
• TB meningitis: Dexamethasone 0.4mg/kg/24h with a reducing course over
6-8 weeks
• TB pericarditis: Prednisolone 60 mg for the first 4 weeks, 30 mg for weeks 5-
8, 15 mg for weeks 9-10 and 5 mg for week 11.
Refer to Table below on Summary of treatment regimens for EPTB.

C. CATEGORY II 2HRZES/ 1HRZE/5HRE

Etiology: PTB or EPTB, previously treated drug-susceptible TB (whether
bacteriologically confirmed or clinically diagnosed)
• Relapse
• Treatment After Failure
• Treatment After Lost to Follow-up (TALF)
• Previous Treatment Outcome Unknown
• Other

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Preferred Regimen:
PEDIATRICS (<15Y):
Intensive phase (2HRZES* + Continuation phase
BODY
1HRZE) (No. of tablets) (5HRE)
WEIGHT
HRZ E (100 mg) HRE+
4 - 7 kg 1 1 1
8 – 11 kg 2 2 2
12 – 15 kg 3 3 3
16 - 24 kg 4 4 4
25 + kg Adult dose and preparations
*Add streptomycin 15 mg/kg BW/d during the first 2 months of the intensive phase, not to
exceed 1 g/d.

ADULTS:
Intensive phase (2HRZES* + Continuation phase
BODY
1HRZE) (No. of tablets) (5HRE)
WEIGHT
HRZES* HRZE HRE
30 - 37 kg 2 2 2
38 – 54 kg 3 3 3
55 – 70 kg 4 4 4
> 70 kg 5 5 5
*Add streptomycin 15 mg/kg BW/d during the first 2 months of the intensive phase, not to
exceed 1 g/d.

Comments:
All retreatment patients are considered as Presumptive DR-TB and should
therefore be tested using Xpert MTB/ Rif Test before initiating Category II
treatment regimen (except if there is no sputum specimen, or there is no access
to Xpert services).

Category II regimen should only be given among SUSCEPTIBLE retreatment cases.

They should immediately be referred to the nearest MDR-TB facility (or other
private or government facility with Xpert/MTB/Rif service) for Rifampicin
susceptibility testing (Xpert). For patients with BW <50 kgs and those >60 yrs. old,
consider streptomycin dosing of 500-700mg or 10mg/kg/d.

Xpert MTB/Rif test shall be done first and result be made available before
starting on any second-line drugs.

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D. CATEGORY IIA 2HRZES/ 1HRZE/9HRE

Etiology: EPTB, previously treated drug-susceptible TB (whether bacteriologically

confirmed or clinically diagnosed) - CNS, bones or joints.

Preferred Regimen:
PEDIATRICS (<15Y):
Intensive phase (2HRZES* + Continuation phase
BODY
1HRZE) (No. of tablets) (5HRE)
WEIGHT
HRZ E (100 mg) HRE+
4 - 7 kg 1 1 1
8 – 11 kg 2 2 2
12 – 15 kg 3 3 3
16 - 24 kg 4 4 4
25 + kg Adult dose and preparations
*Add streptomycin 30 mg/kg BW/d during the first 2 months of the intensive
phase, not to exceed 1 g/d.

ADULTS:
Intensive phase (2HRZES* + Continuation phase
BODY
1HRZE) (No. of tablets) (5HRE)
WEIGHT
HRZES* HRZE HRE
30 - 37 kg 2 2 2
38 – 54 kg 3 3 3
55 – 70 kg 4 4 4
> 70 kg 5 5 5
*Add streptomycin 30 mg/kg BW/d during the first 2 months of the intensive
phase, not to exceed 1 g/d.

Comments:
Pre-treatment recommendations for patients starting Category II regimens:
1. Baseline history and PE for any risk factors for hepatic, renal and ocular toxicity;
sexual history; occupational history; personal/ social personal (including
smoking and alcohol use)
2. Those with risk behavior for HIV or coming from Category A/B HIV areas should
be offered PICT
3. Baseline ALT/crea at the minimum for >60y/o and those with risk factors for
liver or kidney disease
4. Screening for DM (using FBS, RBS or OGTT) for all TB patients
5. Baseline visual acuity and color perception for all TB patients

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E. Standard Regimen Drug Resistant (SRDR)

Etiology: Rifampicin-resistant TB or Multidrug-resistant TB (MDR-TB)

Preferred Regimen:
Shorter Treatment Regimen: Moxifloxacin-Kanamycin-Prothionamide-
Clofazimine-Pyrazinamide-Ethambutol-Isoniazid high dose (MfxKmPtoCfzEZH)
• Strictly provided to MDR/RR-TB only.
• Treatment duration for 9-11 months.

Conventional Treatment Regimen:

• Provided to patients who do not qualify for the Shorter Treatment
• Treatment duration for 20-24 months.

Comments:
Since second-line drugs (SLDs) come in single dose formulations, DOT shall be
done throughout the treatment duration to ensure adherence. Refer to the
treatment centers/ satellite treatment centers for DR-TB management.

F. XDR-TB Regimen

Preferred Regimen:
Treatment shall be individualized based on DST result and history of previous
treatment and managed only by PMDT center.

INDIVIDUAL CONDITIONS/SPECIAL SITUATIONS

A. PEOPLE LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

Preferred Regimen:
In HIV-related TB, the priority is to treat TB. Standard TB regimen for HIV-
associated TB is the same as the general population.

ARV should be initiated after the 2nd week of TB treatment. For patients with TB
meningitis, ARV should be given after the Intensive Phase of TB treatment.
Cotrimoxazole prophylaxis (sulfamethoxazole 800mg/ trimethoprim 160 mg
daily) for Pneumocystis jiroveci pneumonia regardless of CD4 count.

Comments:
All newly diagnosed PLHIV should be screened for active TB. All PLHIV with cough
of any duration, fever, night sweats, or loss of weight shall undergo sputum
collection for Xpert testing. PLHIV without these symptoms should undergo chest
x-ray or clinical assessment to rule out EPTB.

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Should there be cutaneous reactions observed in HIV-infected individuals, it is

important to note that RIF should be reintroduced last.

Efavirenz is the preferred NNRTI for PLHIV on TB treatment. Avoid the use of
nevirapine because of drug-drug interactions. Pyridoxine (Vitamin B6) at 10-25
mg/d.

B. DIABETIS MELLITUS

Preferred Regimen: Same as general population

Comments:
Glucose control should be optimal, referral to specialist is recommended for
difficult to control diabetes

C. NEW MILIARY TB AND MILIARY TB WITH DISSEMINATION

Preferred Regimen: Treat as Category I: 2HRZE/4HR

Comments:
In the absence of meningitis or bone and joint involvement, the effective
treatment regimen for NEW miliary TB cases is Category I.

D. PREGNANCY

Preferred Regimen:
Standard TB regimen for pregnant is the same as the general population. Pregnant
patients taking Isoniazid should be given Pyridoxine (Vitamin B6) at 10-25 mg/d.

Comments:
Always ascertain whether or not a woman is pregnant before she starts TB
treatment. First line anti-TB drugs are safe for pregnant women, EXCEPT
streptomycin (an ABSOLUTE contraindication).

E. BREASTFEEDING/LACTATING WOMEN

Preferred Regimen:
Standard TB regimen for breastfeeding/Lactating women is the same as the
general population. Breastfeeding/Lactating women should be given Pyridoxine
(Vitamin B6) at 10-25mg/d. Supplemental Pyridoxine should be given at 5-10
mg/d to the infant who is taking isoniazid or whose breastfeeding mother is taking
isoniazid.

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Comments:
Breastfeeding woman afflicted with TB should receive a full course of TB
treatment. In lactating mothers on TB treatment, most anti-TB drugs will be found
in breast milk in concentrations equal to only a small fraction of the therapeutic
dose in infants.

F. ORAL CONTRACEPTIVES

Preferred Regimen: Category I: Category I: 2HRZE/4HR

Comments:
Rifampicin interacts with oral contraceptive (OC) medications with a risk of
decreased protective efficacy against pregnancy. Advise a woman receiving OC
while on Rif treatment that she has the following options:
1. Take an OC pill containing a higher dose of estrogen (50 u) following
consultation with a clinician
2. Use another form of contraception

G. LIVER DISEASE / HISTORY OF LIVER DISEASE

Preferred Regimen:
Treatment should be interrupted and generally modified or alternative regimen
used for those with alanine aminotransferase (ALT) elevation >3x the upper limit
of normal (ULN) in the presence of hepatitis symptoms/or jaundice. If ALT is
elevated 5x the ULN, treatment should be interrupted even in the absence of
symptoms. Refer to the appropriate specialist.

H. CHRONIC LIVER DISEASE

Preferred Regimen (For compensated liver cirrhosis):

2HRSE/6HR, 2HSE/10HE, 9HRE

Comments:
Patients undergoing prolonged ethambutol treatment should undergo regular
ophthalmologic screening (visual acuity and red/green color discrimination). For
decompensated liver cirrhosis: Refer to a specialist because use of possible SLDs is
warranted. The more advanced the liver disease, the fewer number of hepatotoxic
drugs should be used.

I. ACUTE VIRAL HEPATITIS

Preferred Regimen:
It is possible to defer TB treatment until acute hepatitis has been resolved. When
it is necessary to treat TB during acute hepatitis, the safest option is the

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combination of streptomycin and ethambutol for 3 months. Once the hepatitis has
resolved, a Continuation Phase of 6 months HR is given (3SE/6HR). If the hepatitis
has not been resolved, SE should be continued for a total of 12 months (12SE).
Refer all patients to a specialist.

J. KNOWN CHRONIC KIDNEY DISEASE

Preferred Regimen:
2HRZE/4HR modified in dosage and frequency based on creatinine clearance.
Thrice weekly instead of daily pyrazinamide and ethambutol is recommended.

Comments:
Please refer to the Table below on Dose Adjustments for Patients with Kidney
Disease. Anti-TB medications should be administered immediately AFTER
hemodialysis or ANYTIME during peritoneal dialysis. SDFs are preferred over FDCs
to facilitate proper dose adjustments. Same adjustments are made for those
receiving second line drugs.

K. RENAL FAILURE (with reduced renal function or receiving hemodialysis)

Preferred Regimen:
H: 300 mg od; or 900 mg 3x per week
R: 600 mg od; or 600 mg 3x per week
Z: 25-35 mg/kg/dose 3x per week (NOT daily)
E: 15-25 mg/kg/dose 3x per week (NOT daily)
S: 12-15 mg/kg/dose 2 or 3x per week

Comments:
Noting the recommendations cited, it is possible to give a 4-drug FDC (HRZE) 3x
per week and then give a 2-drug FDC (HR) for the rest of the week during the
Intensive Phase. Continuation Phase may proceed with 4HR. Otherwise, another
safe option is 2HRZ/4HR. It is recommended that anti-TB medications be taken
after hemodialysis.

Summary of treatment regimens for Extra-pulmonary TB

Site Regimen Recommendation/

Level of Evidence
Central Nervous System 2 HRZE / 10 HR STRONG recommendation,
High quality evidence
Bone and Joints 2 HRZE / 10 HR STRONG recommendation,
Moderate quality evidence
Lymph node 2 HRZE / 4 HR STRONG recommendation,
Moderate quality evidence

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Pericardium 2 HRZE / 4 HR STRONG recommendation,

Low quality evidence
Pleura 2 HRZE / 4 HR STRONG recommendation,
Moderate quality evidence
Liver 2 HRZE / 4 HR STRONG recommendation,
Moderate quality evidence
Gastrointestinal, 2 HRZE / 4 HR STRONG recommendation,
Peritoneum Moderate quality evidence
Kidney and Genitourinary 2 HRZE / 4 HR STRONG recommendation,
tract Low quality evidence

Dose Adjustments for Patients with Kidney Disease

Reference Dose Adjustment

dose
Anti TB Drug (normal GFR ≥ GFR ≤ Peritoneal
renal 30 30 Hemodialysis Dialysis
function) ml/min ml/min
Isoniazid 5 (4-6) None After dialysis None
mg/kg/d
(max 300
mg/d)
Rifampicin 10 (8-12) None After dialysis None
mg/kg/d
(max 600
mg/d)
Pyrazinamide 25 (20-30) None 25-35 25-35 mg/kg, 25-35
mg/ mg/kg, 3x/week, mg/kg,
kg/d (max 3x/week after 3x/week
2 g/d) dialysis
Ethambutol 15 (15-20) GFR > 15-25 15-25 mg/kg, 15-25
mg/ 70 mg/kg, 3x/week, mg/kg,
kg/d (max ml/min: 3x/week after 3x/week
1.2 g/d) None dialysis
GFR <
70
ml/min:
15-25
mg/kg,
3x/week

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REFERENCES
• WHO Treatment of Tuberculosis Guidelines, 4th edition. Geneva, Switzerland: WHO, 2010.
• National Tuberculosis Control Program Manual of Procedures, 5th edition. Sta. Cruz,
Manila: DOH, 2014.
• CPG for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos
– 2016 Update. Manila: Philippine Coalition Against Tuberculosis (PhilCAT); 2016.

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