New TB guidelines from the Canadian Thoracic Society

The Canadian Thoracic Society has released a newly updated version of the Canadian Tuberculosis Standards The eighth edition of the standards includes new sections on cultural competency, new drugs and regimens, new post-TB care recommendations, and a call for a greater role for allied care providers such as pharmacists in TB care. “These new guidelines bring new and practical recommendations to improve care for people impacted by TB throughout Canada,” said respiratory physician Dr. James Johnston, clinical professor of medicine at the University of British Columbia and one of the standards editors and co-authors. Read: Canadian influenza vaccine guidelines for 2022-23 now available The document is a significant update from the 2013 iteration, with several new and updated recommendations for TB diagnosis, treatment and care, he told The Medical Post. TB in Canada is on the rise, with the total number of cases of TB increasing in the last three years. There remain specific groups with elevated risk. For example, individuals born outside Canada make up the largest proportion of people reported with active TB with an incidence rate that has stayed at about 15 individuals per 100,000 population since 2005. Another group disproportionately impacted by TB continues to be Canadian First Nations populations. For example, the active TB disease incidence rate in Inuit communities peaked in 2012 at 251.6 individuals per 100,000 population and in 2020 saw an incidence rate of 70.3 per 100,000 population. “That remains 15 times the overall Canadian rate and is unacceptably high,” said Dr. Johnston. Read: QUIZ: Test your knowledge of asthma management While the previous standards had a chapter on Indigenous populations, the updated content is more robust. It now features a chapter that was led and written by the three Indigenous groups and offers First Nations, Inuit and Métis perspectives. It addresses improving cultural competence for healthcare workers and public health professionals who serve Indigenous peoples. “This chapter should be considered required reading for all care providers who work with people impacted by TB,” said a statement from the CTS. After years of stagnation in TB therapy, new TB treatments have come a long way in a short number of years. Read: If it’s not asthma, what is it? “Preventive treatment for adults and children has improved over the past decade with the introduction of much shorter and safer regimens that include rifampin or rifapentine,” said Dr. Johnston. These have replaced a nine-month course of isoniazid which was the mainstay of TB prevention efforts for decades. Currently, access to Rifapentine is restricted across Canada. A new chapter on TB treatment emphasizes the fundamentals of TB care seen in previous editions, but also highlights the need to support people through TB treatment and mitigate the long-term impacts of the disease. “We are now recognizing the long-term medical and socioeconomic impacts of TB, and we are taking our first steps towards addressing them in these guidelines,” said Dr. Johnston. The chapter also reminds doctors to approach care in ways that are culturally appropriate in terms of patient engagement, education and support. Big changes in drug-resistant TB There are also some big changes in the area of diagnosis and treatment of drug-resistant TB. New rapid molecular tests offer the ability to diagnose the most common forms of drug resistance within a day, and are now recommended to be performed on every person with known TB disease. Read: Guide for Paxlovid use in patients who take DOACs “Rapid molecular tests are especially important for patients with risk factors for drug-resistant TB,” the standards said. As well, “isolates from all TB patients diagnosed with rifampin resistance or multidrug resistance should undergo phenotypic drug susceptibility testing for all anti-TB medicines currently recommended to treat MDR-TB.” The standards also make a call for better access to treatments. “Federal and provincial government agencies, and pharmaceutical companies operating in Canada, should facilitate timely access to second-line drugs for MDR (multidrug resistant) and extensively drug-resistant (XDR)-TB,” it said. Greater role for pharmacists in people with co-infections There is also a newly introduced chapter with details for the management of TB in people who are co-infected with human immunodeficiency virus (HIV), diabetes and liver or kidney diseases. Between 2017 and 2020, 3.5% of individuals who had active TB disease were known to have HIV. The chapter noted that adverse events and treatment interruption are more common in these special populations and that they often warrant close monitoring and additional support. But they also often come with complexities around drug-drug interactions. “Given alterations in TB-drug pharmacokinetics and the potential for severe drug-drug interactions in patients with medical comorbidities, we recommend consultation with an experienced pharmacist,” it stated. Read: Ventilation still needed as part of CPR used in drowning victims A chapter addressing infection prevention and control in various healthcare settings no longer recommends routine periodic testing for most healthcare workers except those who are the at highest risk of exposure. There are also chapters addressing public health aspects such as contact investigation and outbreak management, surveillance and screening of high-risk groups. Most notably, there are new isolation recommendations facilitating more rapid ‘de-isolation’ during TB therapy. “With the recent COVID-19 pandemic, I think we can all relate to the impact of isolation on a person’s social life, livelihood and mental health, it’s important our recommendations recognize this impact and minimize disruptions when possible.”

New TB guidelines from the Canadian Thoracic Society

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