Management of DR-TB ADR: Peripheral Neuropathy

Serious Adverse Drug Reaction (ADR), such as peripheral neuropathy, may occur during Drug-resistant TB  (DR-TB) treatment.

Suspected agent(s): Linezolid (Lzd), Cycloserine (Cs), Isoniazid (H), Amikacin (Am), Fluoroquinolone (FQ), rarely Ethionamide (Eto), Ethambutol​ (E)

Suggested Management Strategies​

• To prevent the occurrence of such adverse reactions, all patients on Multidrug-resistant TB (MDR-TB) medicines should receive pyridoxine daily. ​
• The commonest offending agent is Linezolid (Lzd), almost 60–70% of patients on Lzd 600 mg/day may develop neuropathy and pyridoxine does not help in preventing Lzd-induced neuropathy. Early recognition of neuropathy symptoms and early dose reduction of Lzd helps to prevent progression. ​
• If there is no improvement or symptoms worsen, Amitriptyline 25 mg will be added (to be avoided with Bdq).
• Correct any vitamin or nutritional deficiencies and increase pyridoxine to the maximum daily dose (100 mg per day).​
• Consider whether the dose of Cs can be reduced without compromising the regimen. If H is being used (especially high dose Isoniazid (H^h)), consider stopping it.

Medical Treatment of Peripheral Neuropathy​

• Non-steroidal anti-inflammatory drugs or acetaminophen may help to alleviate symptoms.​
• Treatment with tricyclic antidepressants, such as amitriptyline (start with 25 mg at bedtime, the dose may be increased to a maximum of 150 mg), can be tried. ​
• Do not use tricyclic antidepressants with selective serotonin reuptake inhibitors and Bedaquilin (Bdq).
• Medication can be discontinued (rarely), only if an alternative drug is available and the regimen is not compromised.

Points to Note​

• Patients with comorbid diseases (diabetes, HIV, alcohol dependence) are likely to develop peripheral neuropathy.​
• Neuropathy associated with Lzd is common after prolonged use and may be irreversible. Thus, suspension of this drug should be strongly considered when neuropathy persists despite the above measures.

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.

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