Red Flags
- Massive haemoptysis (>200 mL in 24h or any haemoptysis with respiratory compromise) — interventional bronchoscopy or arterial embolisation[1]
- Drug-resistant TB on Xpert MTB/RIF (rifampicin resistance) — refer to Programmatic Management of Drug-Resistant TB (PMDT) centre; do NOT start standard first-line[1]
- Severe ATT-induced hepatitis (ALT >5× ULN or symptomatic) — pause ATT; sequential reintroduction under specialist supervision[1]
- TB-HIV co-infection — start TB therapy first; ART within 2 weeks if CD4 <50, within 8 weeks if higher; manage IRIS[1]
First-line treatment
Interventions
- Directly observed treatment[1]All ATT under DOT (treatment supporter, in-person or video). Drug procurement through NTEP free at point of care; Nikshay Poshan Yojana provides nutritional support
- Sputum monitoring[1]Repeat sputum at end of intensive phase (2 months), 5 months, and end of treatment (6 months). Conversion drives extension of intensive phase or treatment failure declaration
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| HRZE fixed-dose combination (intensive phase)[1] | First-line antitubercular FDC | Weight-band: 30–37 kg: 2 FDC tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 2 months | Weight-band paediatric FDC per NTEP | 2HRZE intensive phase. NTEP uses daily regimen (replaced thrice-weekly) |
| HR (continuation phase)[1] | Isoniazid + rifampicin FDC | Weight-band: 30–37 kg: 2 tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 4 months | Weight-band paediatric FDC | 4HR continuation phase. Total 6-month regimen 2HRZE/4HR for new pulmonary TB |
| Pyridoxine (vitamin B6)[1] | Adjunctive co-prescription | 10 mg PO daily during ATT | 5–10 mg daily | Prevents isoniazid-induced peripheral neuropathy; especially in pregnancy, malnutrition, alcohol use |
| 1HP (rifapentine + isoniazid) for TPT[1] | TB preventive therapy | Rifapentine 600 mg + isoniazid 300 mg PO daily × 28 days | Weight-band per NTEP | TB preventive therapy for contacts and PLHIV; 1HP shorter and effective; 3HP and 6H also available |
HRZE fixed-dose combination (intensive phase)[1]
First-line antitubercular FDC
- Adult
- Weight-band: 30–37 kg: 2 FDC tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 2 months
- Paediatric
- Weight-band paediatric FDC per NTEP
2HRZE intensive phase. NTEP uses daily regimen (replaced thrice-weekly)
HR (continuation phase)[1]
Isoniazid + rifampicin FDC
- Adult
- Weight-band: 30–37 kg: 2 tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 4 months
- Paediatric
- Weight-band paediatric FDC
4HR continuation phase. Total 6-month regimen 2HRZE/4HR for new pulmonary TB
Pyridoxine (vitamin B6)[1]
Adjunctive co-prescription
- Adult
- 10 mg PO daily during ATT
- Paediatric
- 5–10 mg daily
Prevents isoniazid-induced peripheral neuropathy; especially in pregnancy, malnutrition, alcohol use
1HP (rifapentine + isoniazid) for TPT[1]
TB preventive therapy
- Adult
- Rifapentine 600 mg + isoniazid 300 mg PO daily × 28 days
- Paediatric
- Weight-band per NTEP
TB preventive therapy for contacts and PLHIV; 1HP shorter and effective; 3HP and 6H also available
Safety-net
- Take all four (or two) ATT pills together every day even when feeling well — interruption causes resistance and relapse[1]
- Watch for jaundice, severe vomiting, vision changes, or numb hands/feet — same-day medical review (drug toxicity)[1]
- Cover your mouth when coughing during the first 2 weeks of treatment to protect family contacts; ensure household members are screened[1]
Referral criteria
- Rifampicin-resistant TB on XpertPMDT centre — switch to all-oral shorter MDR regimen[1]
- Treatment failure (smear-positive at 5 months) or recurrenceTB specialist for repeat DST and second-line evaluation[1]
- Severe ATT hepatitis or other major adverse eventTB specialist or hospital admission for sequential reintroduction[1]
- TB-HIV co-infectionJoint NTEP and ART centre[1]
Clinical summary
Diagnosis, treatment, and follow-up of drug-sensitive pulmonary TB under the National TB Elimination Programme; daily fixed-dose combination regimen with DOT.