Management of DR-TB ADR: Gastrointestinal Symptoms [Nausea and Vomiting]

Suggested Management Strategies

• If there is nausea or vomiting: Take drugs embedded in a banana.
• If vomiting persists: Administer drugs 1 hour after 1 tablet of Domperidone and/or Omeprazole or Famotidine/ Ranitidine. No other antacids should be given since they interfere with the absorption of Fluoroquinolone (FQ).
• For severe vomiting:
  • Monitor the patient’s hydration status
  • Assess patient for danger signs including dehydration and electrolyte disturbance
  • If required, initiate rehydration treatment and correct electrolyte disturbances
  • Temporarily withhold drugs, and conduct tests to rule out other causes of vomiting like hepatitis

If there is blood in the vomit: Check haemoglobin and treat for possible bleeding ulcers

If the offending drug is Ethionamide (Eto): Administer it with milk or at bedtime to avoid nausea.

With Bedaquiline (Bdq), Metoclopramide is preferred over Ondansetron; and Ranitidine is preferred over Omeprazole.

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Points to Note

• Nausea and vomiting are universal in the early weeks of treatment and usually abate with time on treatment and adjunctive therapy.
• Some nausea and even vomiting may need to be tolerated at least in the initial period.
• Creatinine and electrolytes should be checked in case of severe vomiting. Give intravenous fluids and replace electrolytes as needed.
• Another strategy is to stop the responsible medicine for 2-3 days and then add it back, gradually increasing the dose (advise the patient that the medicine will be increased back to a therapeutic dose in a way that is better tolerated).
• Ondansetron prolongs QT interval; avoid the use of ondansetron with Bdq or Dlm.
• For patients particularly anxious about nausea, (and with “anticipatory nausea and vomiting”) a small dose of an anti-anxiety medicine (5 mg of diazepam) can help when given 30 minutes prior to intake of anti-TB drugs.

Resources

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2020.
• 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.