Management of DR-TB ADR: Psychotic Symptoms

Adverse Drug Reactions (ADRs), such as psychotic symptoms, may occur from the Drug-resistant TB (DR-TB) treatment regimen.

Suspected agent(s): Cycloserine (Cs), Isoniazid (H), Fluoroquinolone (FQ)

Suggested Management Strategies

• Stop the suspected agent for a short period (1-4 weeks) while the psychotic symptoms are brought under control. 
• The most likely drug is Cs followed by high dose isoniazid (H^h). Lower the dose/ discontinue the suspected agent (if it can be done without compromising the regimen).
• If moderate to severe symptoms persist, initiate antipsychotic treatment (haloperidol). 
• Hospitalize in a ward with psychiatric expertise if the patient is at risk to hurt himself/ herself or others.
• Once all the symptoms resolve and the patient is off Cs, antipsychotic treatment can be tapered off. 
• If Cs is continued at a lower dose, antipsychotic treatment may need to be continued and any attempts of tapering off should be done after referring to a psychiatrist trained in the adverse effects of second-line anti-TB drugs.

Point to Note

• Some patients will be required to continue antipsychotic treatment.
• A previous history of psychiatric disease is not an absolute contraindication to Cs, but its use may increase the likelihood of psychotic symptoms that are found to be developing during treatment.
• Some patients will tolerate Cs with an antipsychotic drug, but this should be done in consultation with a psychiatrist as these patients will be required to be under special observation; this should be done only when there is no other alternative.
• Psychotic symptoms are generally reversible upon completion of DR-TB treatment or cessation of the offending agent.
• Always check creatinine in patients with new-onset psychosis. A decrease in renal function can result in high blood levels of Cs, which can cause psychosis.

​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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