|
Indian Pediatr 2013;50: 800-801 |
|
Updated National Guidelines for Pediatric
Tuberculosis: Concerns Regarding Neurotuberculosis
|
Jitender Kumar Sahu
Assistant Professor, Pediatric Neurology Division,
Department of Pediatrics, Post Graduate Institute of Medical Education &
Research, Chandigarh, India.
Email: [email protected]
|
I read with interest the recent Updated National guidelines
for pediatric tuberculosis in India [1]. There are few
important concerns in guidelines regarding neurotuberculosis
which I wish to highlight.
First, there are discrepancies in dose
ranges of isoniazid, rifampicin and pyrazinamide from the
latest WHO guidelines and should be corrected. WHO currently
recommends the following daily doses of antituberculosis
medicines for the treatment of tuberculosis in children:
isoniazid–10 mg/kg (range 10-15 mg/kg); rifampicin–15 mg/kg
(range 10–20 mg/kg), pyrazinamide-35 mg/kg (30-40 mg/kg);
ethambutol–20 mg/kg (15-25 mg/kg) [2]. It is important as
upper end of the recommended dose range should be considered
in neurotuberculosis in view of uncertain penetration of
antituberculosis medicines into the central nervous system.
The dose range suggested in published national guidelines
probably follows WHO 2006 guidelines and should be corrected
according to WHO 2009 guidelines. Second concern is
regarding the duration of antitubercular therapy in
neurotuberculosis. WHO recommends that duration of
antitubercular therapy should be at least 12 months [3].
Similarly, a systemic review also identifies that there is
no evidence base for shorter duration regime [4]. So, the
recommendation of shorter 9 months duration is inappropriate
and not evidence-based. Third, selection of third drug as
ethambutol in continuation phase of previously treated cases
has poor evidence-base with regard to neuro-tuberculosis. As
pyrazinamide has better central nervous system penetration
and bactericidal effect, it is probably a better choice as
the third drug in continuation phase of previously treated
cases.
Overall, I must congratulate authors for
very comprehensive guideline and I hope the revised version
would focus on the concerns regarding neuro-tuberculosis.
References
1. Kumar A, Gupta D, Sharath BN, Singh V,
Sethi GR, Prasad J. Updated National Guidelines for
Pediatric Tuberculosis in India, 2012. Indian Pediatr.
2013;50: 301-6.
2. World Health Organization. Dosing
instructions for the use of currently available fixed-dose
combination TB medicines for children, 2009. Available from:
http://www.who.int/tb/challenges/interim_paediatric_fdc_
dosing_instructions_sept09.pdf.
3. World Health Organization. Rapid
Advice 2010: Treatment of tuberculosis in children.
Available from: http://apps.who.int/iris/bitstream/10665/44444/1/9789241
500449_eng.pdf.
4. Prasad K, Sahu JK. Duration of
anti-tubercular treatment in tuberculous meningitis:
challenges and opportunity. Neurol India. 2010;58:723-6.
|
|
|
|