TB treatment in patients with underlying liver cirrhosis is challenging because with limited hepatic functional reserve, they are at particular risk of liver decompensation following drug-induced hepatotoxicity. For patients with liver cirrhosis of any stage, PZA and INH are best avoided143 and establishing a hepatic-sparing TB regimen in consultation with a TB expert is recommended.
Although rifampin is associated with drug-induced liver injury, the risk is significantly lower than with either INH or PZA.144 Furthermore, rifampin is considered crucial to achieving relapse-free (or long-term) TB cure. Thus, rifampin is often used in patients with compensated liver cirrhosis (Child-Pugh A) although is usually avoided in those with overt liver decompensation (Child-Pugh B or C).143 Fluroquinolones, especially levofloxacin, are associated with low rates of hepatotoxicity and are sometimes used in people with decompensated liver cirrhosis.145,146
Serological screening for viral hepatitis infection should be a part of routine testing at the time of TB treatment initiation for all people with TB, regardless of whether liver disease is apparent on initial testing.147,148 Viral hepatitis and TB share epidemiologic associations: both hepatitis B (HBV) and C (HCV) are more prevalent in people from Asian and African regions.149,150 In Canada, HCV infection is prevalent in people who use drugs, those who are unstably housed and those born before 1965. Viral hepatitis is also a risk factor for drug-induced liver injury during TB treatment.151–155
Observational data has shown that antiviral treatment of active hepatitis B during TB therapy reduces the incidence of subsequent drug-induced liver injury and hospitalization. TB patients found to be seropositive for hepatitis B surface antigen at the time of TB diagnosis should be promptly referred for hepatitis B treatment.156
Currently recommended antiviral treatment regimens for chronic hepatitis C infection are considered incompatible with the rifamycin class because of significant drug-interactions.157 Antiviral therapy for HCV is thus usually deferred until completion of rifamycin-based TB treatment. Collaboration with a hepatitis specialist is recommended.
We conditionally recommend routine serological screening for viral hepatitis at the time of TB treatment initiation (poor evidence).
Good practice statement
When initiating active TB therapy in people with liver cirrhosis, consultation with a TB expert is advised. A hepatic-sparing regimen, which might exclude pyrazinamide and isoniazid, may be required.
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