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World J Gastroenterol. May 21, 2014; 20(19): 5760-5772
Published online May 21, 2014. doi: 10.3748/wjg.v20.i19.5760
Antitubercular therapy in patients with cirrhosis: Challenges and options
Naveen Kumar, Chandan Kumar Kedarisetty, Sachin Kumar, Vikas Khillan, Shiv Kumar Sarin
Naveen Kumar, Chandan Kumar Kedarisetty, Shiv Kumar Sarin, Departments of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi 110070, India
Sachin Kumar, Departments of Pulmonology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi-110070, India
Vikas Khillan, Departments of Microbiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi-110070, India
Author contributions: All authors contributed to the manuscript.
Correspondence to: Dr. Shiv Kumar Sarin, MD, DM, DSc, FNA, Professor and Head, Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, Plot No.D-1, New Delhi 110070, India. shivsarin@gmail.com
Telephone: +91-11-46300000 Fax: +91-11-26123504
Received: October 29, 2013
Revised: December 31, 2013
Accepted: January 20, 2014
Published online: May 21, 2014
Abstract

Tuberculosis (TB) has been a human disease for centuries. Its frequency is increased manyfold in patients with liver cirrhosis. The gold standard of TB management is a 6-mo course of isoniazid, rifampicin, pyrazinamide and ethambutol. Although good results are seen with this treatment in general, the management of patients with underlying cirrhosis is a challenge. The underlying depressed immune response results in alterations in many diagnostic tests. The tests used for latent TB have many flaws in this group of patients. Three of four first-line antitubercular drugs are hepatotoxic and baseline liver function is often disrupted in patients with underlying cirrhosis. Frequency of hepatotoxicity is increased in patients with liver cirrhosis, frequently leading to severe liver failure. There are no established guidelines for the treatment of TB in relation to the severity of liver disease. There is no consensus on the frequency of liver function tests required or the cut-off used to define hepatotoxicity. No specific treatment exists for prevention or treatment of hepatotoxicity, making monitoring even more important. A high risk of multidrug-resistant TB is another major worry due to prolonged and interrupted treatment.

Keywords: Antitubercular therapy, Drug hepatotoxicity, Multidrug-resistant tuberculosis, Immune dysfunction

Core tip: Treatment of tuberculosis (TB) in patients with underlying cirrhosis is a challenge because of the compromised liver functions and high risk of hepatotoxicity. There is no consensus regarding the treatment and monitoring of TB in this group of patients. This paper reviews the differences in diagnosis, treatment, monitoring, hepatotoxicity and other issues in treatment of TB in patients with cirrhosis. Suggestions for treatment of TB in patients with different grades of cirrhosis, as well as monitoring guidelines, are provided. Finally, issues such as liver transplantation, multidrug-resistant TB and reactivation of TB by interferon are briefly reviewed.