Management of DR-TB ADR: Gastritis, abdominal pain

Adverse Drug Reactions (ADRs), such as gastritis and abdominal pain, may occur from the Drug-resistant TB (DR-TB) treatment regimen.

Suspected agent(s): Para Aminosalicylic Acid (PAS), Ethionamide (Eto), Clofazimine (Cfz), Linezolid (Lzd), Fluoroquinolone (FQs), Isoniazid (H), Ethambutol (E), and Pyrazinamide (Z)

• Abdominal pain is often associated with serious adverse effects, such as pancreatitis {Lzd, Bedaquiline (Bdq)}, lactic acidosis and hepatitis. 
• If any of these are suspected, it is important to obtain appropriate laboratory tests to confirm and suspend the suspected agent.

Suggested Management Strategies

• For gastritis-like symptoms (epigastric burning or discomfort, sour taste in mouth associated with reflux) initiate medical treatment with the use of H2-blockers (Ranitidine 150 mg twice daily or 300 mg once daily).
• Proton-pump inhibitors (Omeprazole 20 mg once daily) should be avoided along with Bdq.
• Avoid use of antacids as they decrease absorption of FQ.
• For severe abdominal pain, stop suspected agent(s) for short periods of time (1-7 days).
• Lower the dose of the suspected agent or discontinue, if this can be done without compromising the regimen.

Points to Note

• Severe gastritis, as manifested by blood in the vomit or stool, is relatively rare but should always be treated to facilitate adherence to treatment.
• If antacids must be used, they should be carefully timed to not interfere with absorption of FQ (take two hours before or three hours after anti-TB drugs).
• Stop any non-steroidal anti-inflammatory drugs the patient may be taking.
• Diagnose and treat Helicobacter pylori infections.
• Severe abdominal distress has been reported with the use of Cfz. Although these reports are rare, if this occurs, Cfz should be suspended.

Resources

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.
• Ready Reckoner for Medical Officer- Adverse Drug Reactions Associated with Anti-TB Drugs Identification and Management, 2019.   
• Technical and Operational Guidelines for TB in India, 2016.

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