Papulonecrotic Tuberculids Medication
- Author: Manuel Valdebran, MD; Chief Editor: William D James, MD more...
The goal of pharmacotherapy is to eradicate the underlying mycobacterial infection that causes papulonecrotic tuberculid.
These agents are effective in the treatment of mycobacterial infections. Therapy with a 4-drug combination of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) is recommended to avoid the development of resistance.
Isoniazid is the best combination of effectiveness, low cost, and minor adverse effects. It is a first-line drug unless resistance or another contraindication is known. Therapeutic regimens of less than 6 months demonstrate an unacceptably high relapse rate. Coadministration of pyridoxine is recommended to minimize the risk of peripheral neuropathy secondary to isoniazid therapy. Prophylactic doses of 6-50 mg of pyridoxine daily are recommended. Twice-weekly dosing is not recommended in HIV patients with CD4 lymphocyte counts of less than 100 cells/µL.
Rifampin is for use in combination with at least one other anti-TB drug. It inhibits DNA-dependent bacterial RNA polymerase but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 months or until 6 months have elapsed from conversion to sputum culture negativity.
Pyrazinamide is a pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on the concentration of the drug attained at the site of infection; its mechanism of action is unknown. Administer for the initial 2 months of a 6-month or longer treatment regimen for drug-susceptible patients. Treat drug-resistant patients with individualized regimens.
Ethambutol diffuses into actively growing mycobacterial cells, such as tubercle bacilli. It impairs cell metabolism by inhibiting the synthesis of one or more metabolites, which, in turn, causes cell death. No cross-resistance is demonstrated. Mycobacterial resistance is frequent with previous therapy. Use ethambutol in these patients in combination with second-line drugs that have not been previously administered. Administer daily until permanent bacteriologic conversion and maximal clinical improvement is seen. Absorption is not significantly altered by food.
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