Management of DR-TB ADR: Psychotic Symptoms

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Adverse Drug Reactions (ADRs), such as psychotic symptoms, may occur from the Drug-resistant TB (DR-TB) treatment regimen.

Suspected agent(s): Cycloserine (Cs), Isoniazid (H), Fluoroquinolone (FQ)

Suggested Management Strategies

Stop the suspected agent for a short period (1-4 weeks) while the psychotic symptoms are brought under control.
The most likely drug is Cs followed by high dose isoniazid (H^h). Lower the dose/ discontinue the suspected agent (if it can be done without compromising the regimen).
If moderate to severe symptoms persist, initiate antipsychotic treatment (haloperidol).
Hospitalize in a ward with psychiatric expertise if the patient is at risk to hurt himself/ herself or others.
Once all the symptoms resolve and the patient is off Cs, antipsychotic treatment can be tapered off.
If Cs is continued at a lower dose, antipsychotic treatment may need to be continued and any attempts of tapering off should be done after referring to a psychiatrist trained in the adverse effects of second-line anti-TB drugs.

Point to Note

Some patients will be required to continue antipsychotic treatment.
A previous history of psychiatric disease is not an absolute contraindication to Cs, but its use may increase the likelihood of psychotic symptoms that are found to be developing during treatment.
Some patients will tolerate Cs with an antipsychotic drug, but this should be done in consultation with a psychiatrist as these patients will be required to be under special observation; this should be done only when there is no other alternative.
Psychotic symptoms are generally reversible upon completion of DR-TB treatment or cessation of the offending agent.
Always check creatinine in patients with new-onset psychosis. A decrease in renal function can result in high blood levels of Cs, which can cause psychosis.

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