Red Flags
- Tubercular meningitis with raised intracranial pressure or hydrocephalus — neurosurgical evaluation; corticosteroids alongside ATT[1]
- Spinal TB (Pott's spine) with neurological deficit — emergency surgical decompression plus ATT[1]
- Miliary TB with respiratory failure or CNS involvement — admit; ICU; ATT plus high-dose corticosteroids; rule out HIV[1]
- TB pericarditis with cardiac tamponade — emergency pericardiocentesis; ATT plus corticosteroids[1]
First-line treatment
Interventions
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| HRZE (isoniazid + rifampicin + pyrazinamide + ethambutol) | First-line antitubercular fixed-dose combination | March 2022 NTEP STW adult FDC daily tablets: 25–34 kg, 2; 35–49 kg, 3; 50–64 kg, 4; 65–75 kg, 5; >75 kg, 6. Intensive-phase tablet contains isoniazid 75 mg/rifampicin 150 mg/pyrazinamide 400 mg/ethambutol 275 mg. [4] | Weight-band per NTEP paediatric tables | The March 2022 ICMR NTEP STW gives 2HRZE/4HRE for general drug-sensitive TB; extrapulmonary site-specific duration and continuation choices must follow the relevant workflow. [4] |
| Pyridoxine (vitamin B6)[1] | Adjunctive co-prescription | 10 mg PO daily during ATT | 5–10 mg daily | Prevents isoniazid-induced peripheral neuropathy |
| Dexamethasone (TBM and TB pericarditis)[1] | Glucocorticoid adjunct | TBM: dexamethasone 0.4 mg/kg/day IV tapering over 6–8 weeks. TB pericarditis: prednisolone 60 mg/day for 4 weeks then taper | 0.3 mg/kg/day (TBM) | Reduces mortality in TBM and prevents constriction in pericarditis |
| MDR/XDR-TB regimen (BPaL/BPaLM)[2] | All-oral shorter regimen for MDR-TB | Bedaquiline + pretomanid + linezolid (± moxifloxacin) for 6 months per WHO 2024 update | — | Specialist (programmatic management of drug-resistant TB) only. DST-driven; shorter than 18-month regimens |
HRZE (isoniazid + rifampicin + pyrazinamide + ethambutol)
First-line antitubercular fixed-dose combination
- Adult
- March 2022 NTEP STW adult FDC daily tablets: 25–34 kg, 2; 35–49 kg, 3; 50–64 kg, 4; 65–75 kg, 5; >75 kg, 6. Intensive-phase tablet contains isoniazid 75 mg/rifampicin 150 mg/pyrazinamide 400 mg/ethambutol 275 mg. [4]
- Paediatric
- Weight-band per NTEP paediatric tables
The March 2022 ICMR NTEP STW gives 2HRZE/4HRE for general drug-sensitive TB; extrapulmonary site-specific duration and continuation choices must follow the relevant workflow. [4]
Pyridoxine (vitamin B6)[1]
Adjunctive co-prescription
- Adult
- 10 mg PO daily during ATT
- Paediatric
- 5–10 mg daily
Prevents isoniazid-induced peripheral neuropathy
Dexamethasone (TBM and TB pericarditis)[1]
Glucocorticoid adjunct
- Adult
- TBM: dexamethasone 0.4 mg/kg/day IV tapering over 6–8 weeks. TB pericarditis: prednisolone 60 mg/day for 4 weeks then taper
- Paediatric
- 0.3 mg/kg/day (TBM)
Reduces mortality in TBM and prevents constriction in pericarditis
MDR/XDR-TB regimen (BPaL/BPaLM)[2]
All-oral shorter regimen for MDR-TB
- Adult
- Bedaquiline + pretomanid + linezolid (± moxifloxacin) for 6 months per WHO 2024 update
- Paediatric
- —
Specialist (programmatic management of drug-resistant TB) only. DST-driven; shorter than 18-month regimens
Safety-net
- Take ATT every day even when feeling well — interruption causes resistance and relapse; full course is essential[1]
- Watch for jaundice, severe vomiting, vision changes, or numb hands/feet during ATT — same-day medical review (drug toxicity)[1]
- Tell your dentist, surgeon, or any other doctor that you are on ATT — drug interactions are common (especially with rifampicin)[1]
Referral criteria
- TB meningitis or spinal TB with neurological deficitNeurology / neurosurgery and ID urgently[1]
- Drug-resistant TB (rifampicin-resistant on Xpert, MDR/XDR)Programmatic Management of Drug-Resistant TB (PMDT) centre[2]
- Treatment failure or relapseTB specialist for re-evaluation and DST[1]
- Severe ATT-related hepatitis (ALT >3× ULN with symptoms or >5× without)Hospital admission; pause ATT; sequential reintroduction under supervision[1]
Clinical summary
Diagnosis and treatment of extrapulmonary TB (lymph node, pleural, abdominal, CNS, bone, miliary); longer durations for CNS, bone, and disseminated disease.
References
- 1.Index-TB Guidelines for Extrapulmonary TB; NTEP Technical Operational Guidelines (2022); WHO Consolidated Guidelines on TB Treatment 2022 (2022)
- 2.WHO Consolidated Guidelines on Tuberculosis: Drug-Resistant TB Treatment, 2024 Update. WHO, Geneva (2024)
- 3.Standard Treatment Workflows: Adult Extrapulmonary Tuberculosis (March 2022). ICMR (2022)
- 4.Standard Treatment Workflow: National Tuberculosis Elimination Programme (March 2022). ICMR (2022)