This handout is for pulmonary tuberculosis (drug-susceptible). Your care team identified this based on: cough ≥ 2–3 wk with fever, night sweats, weight loss, or hemoptysis — who 4-symptom screen (ats/cdc/idsa 2016 nahid; who 2024).
Other reasons your team may use this plan: hemoptysis + subacute constitutional illness in endemic-country / idu / homeless / hcw / hiv+ host (ats/cdc/idsa 2016 nahid); upper-lobe / apical cavitation or reactivation pattern on cxr (ats/cdc/idsa 2016 nahid); afb-smear positive sputum or xpert mtb/rif (ultra) positive (dorman lancet id 2018 pmid 29198911).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| isoniazid | Adult: 5 mg/kg/day PO (max 300 mg) daily for 6-mo standard regimen; 15 mg/kg twice/thrice weekly DOT; 4-mo regimen: standard daily INH × 4 mo; 3HP-LTBI: weight-banded 15 mg/kg weekly × 12 doses (max 900 mg) | PO | daily (intensive + continuation) or weekly (3HP) | ATS/CDC/IDSA 2016 Nahid PMID 27516382 — backbone of every drug-susceptible regimen. Bactericidal + sterilising. Pyridoxine 25–50 mg/d MANDATORY co-administration to prevent peripheral neuropathy. Hepatotoxicity baseline + symptom-driven LFT monitoring; hold for ALT >3× ULN symptomatic or >5× ULN asymptomatic. |
| rifampin | Adult: 10 mg/kg/day PO (max 600 mg) daily for both intensive and continuation phases of 6-mo regimen; 4R-LTBI alternative: 10 mg/kg/d × 4 mo. Substitute rifabutin if PI-based or some INSTI-based ART | PO | daily | ATS/CDC/IDSA 2016 Nahid — sterilising backbone of all rifamycin-containing regimens. Major CYP3A4 inducer — DDI with HIV ART (PI, some INSTI), anticoagulants, oral contraceptives, calcineurin inhibitors, statins, anticonvulsants. Orange-discolours secretions (counsel). Hepatotoxic; flu-like syndrome on intermittent dosing. |
| pyrazinamide | Adult weight-banded: 40–55 kg → 1000 mg/d; 56–75 kg → 1500 mg/d; 76–90 kg → 2000 mg/d (max 2 g daily). 2-mo intensive phase only of 6-mo regimen; full 4 mo of the Dorman 2021 4-mo rifapentine+moxi regimen | PO | daily | ATS/CDC/IDSA 2016 Nahid — accelerates 2-mo culture conversion; sterilising. Hepatotoxic; hyperuricaemia (usually asymptomatic — do not treat unless gout flare). Renal-adjust: CrCl<30 → 25–35 mg/kg 3×/wk post-dialysis. AVOID in pregnancy in some guidelines (acceptable per WHO 2024 / ATS 2016 — limited teratogenicity data; benefits > risks). |
| ethambutol | Adult weight-banded: 40–55 kg → 800 mg/d; 56–75 kg → 1200 mg/d; 76–90 kg → 1600 mg/d (max 1.6 g daily). 2-mo intensive only; DROP once DST confirms pan-susceptibility | PO | daily | ATS/CDC/IDSA 2016 Nahid — added pending DST to cover unsuspected INH resistance; bacteriostatic. Optic neuritis (dose- and duration-dependent) — baseline Snellen + Ishihara, monthly while on therapy; hold immediately for any visual change. Renal-adjust: CrCl<30 → 15–25 mg/kg 3×/wk post-dialysis. (SAFETY-CRITICAL: prompt-seed RxCUI 4083 was ESTRADIOL — corrected to 4110 via RxNav reverse lookup 2026-05-26.) |
| rifapentine | 4-mo Dorman 2021 regimen: 1200 mg PO daily × 2 mo intensive + × 2 mo continuation (long half-life rifamycin component). 3HP-LTBI: weight-banded once-weekly (32.1–49.9 kg → 750 mg; ≥ 50 kg → 900 mg) × 12 doses | PO | daily (Dorman 4-mo) or weekly (3HP) | Dorman NEJM 2021 PMID 33951360 — INH+rifapentine+moxi+PZA × 2 mo → INH+rifapentine+moxi × 2 mo NON-INFERIOR (TB cure 84.6% vs 85.4% for 6-mo regimen). Sterling NEJM 2011 PMID 22150035 — 3HP LTBI completion 82.1% vs 9H 69.0%, TB development 0.19% vs 0.43%, hepatotoxicity 0.4% vs 2.7%. CYP3A4 inducer (caution with ART). |
| rifabutin | Adult: 300 mg PO daily as substitute for rifampin when PI-based or some INSTI-based ART; dose adjust per concurrent ART per DHHS table | PO | daily | ATS/CDC/IDSA 2016 Nahid — weaker CYP3A4 induction than rifampin; preferred rifamycin with PI ART. Uveitis (dose-related), leukopenia, polyarthralgia. (SAFETY-CRITICAL: prompt-seed 9383 was empty {} — corrected to 55672 via RxNav reverse lookup 2026-05-26.) |
| moxifloxacin | 400 mg PO daily — component of Dorman 2021 4-mo regimen × 4 mo total | PO | daily | Dorman NEJM 2021 PMID 33951360 — non-inferior 4-mo regimen anchor. QTc prolongation (avoid with class IA/III antiarrhythmics, methadone, ondansetron); tendinopathy / tendon rupture (age, steroids, transplant); CNS effects. Avoid in pregnancy + age <18 yr unless no alternative. |
| pyridoxine | 25–50 mg PO daily — MANDATORY co-administration with every INH-containing regimen | PO | daily | ATS/CDC/IDSA 2016 Nahid — prevents INH-induced peripheral neuropathy (B6 antagonism); strongly recommended for pregnancy, breastfeeding, HIV, alcohol-use disorder, DM, uraemia, malnutrition, seizure history. (SAFETY-CRITICAL: prompt-seed 8696 was empty {} — corrected to 684879 via RxNav reverse lookup 2026-05-26.) |
| dexamethasone | TB meningitis only: dexamethasone 0.4 mg/kg/day IV taper over 6–8 wk (NOT for routine pulmonary disease) | IV/PO | tapered | ATS/CDC/IDSA 2016 Nahid; Thwaites NEJM 2004 (TB meningitis adjunct) — survival benefit in TB meningitis only. NOT used for routine pulmonary TB. Severe paradoxical TB-IRIS post-ART start may warrant short-course steroids per DHHS OI 2024. |
| prednisolone | TB pericarditis: prednisolone 120 mg/d taper over 6 wk per IMPI 2014 (not for pulmonary disease) | PO | tapered | IMPI Mayosi NEJM 2014 — prednisolone in TB pericarditis reduced constrictive pericarditis + hospitalisation; effect modest, did not lower mortality. HIV+: increased Kaposi sarcoma signal observed. NOT for routine pulmonary TB. (Verified RxCUI 8638 = prednisolone IN; distinguished from prednisone 8635.) |
Plan: Drug-susceptible active TB + LTBI regimen ladder (ATS/CDC/IDSA 2016 Nahid; Study 31 Dorman NEJM 2021; PREVENT-TB Sterling NEJM 2011; CDC LTBI 2020; WHO 2024)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
End-of-treatment cure assessment per WHO/ATS (culture-negative at end of therapy; treatment-completed if doses verified). Close-contact investigation → IGRA / TST + symptom screen + LTBI evaluation/treatment (CDC LTBI 2020 Sterling — 3HP preferred). Mandatory public-health reporting and case closure. Adherence + relapse education; relapse usually within 6–12 mo (highest if cavitary + month-2 culture+). Long-term follow-up for late toxicity and post-TB lung function (Nahid 2016 PMID 27516382; CDC LTBI 2020)
Guideline: ATS/CDC/IDSA 2016 Treatment of Drug-Susceptible Tuberculosis CPG (Nahid et al, Clin Infect Dis 2016 PMID 27516382) + WHO 2024 Consolidated Guidelines on Tuberculosis Treatment + CDC/NTCA LTBI 2020 (Sterling MMWR Recomm Rep 2020) — anchored by Study 31/A5349 (Dorman NEJM 2021 PMID 33951360), PREVENT-TB (Sterling NEJM 2011 PMID 22150035), and Xpert Ultra (Dorman Lancet ID 2018 PMID 29198911).