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TB Drug Reintroduction Order — SCE Infectious Diseases MCQ

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ModerateTuberculosisTB Drug Reintroduction OrderSCE Infectious Diseases

A 45-year-old man with TB develops drug-induced hepatitis (ALT 800 U/L) during the intensive phase. All hepatotoxic drugs are stopped. LFTs normalise after 2 weeks. When reintroducing drugs, which should be restarted FIRST?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Rifampicin — it is the most important anti-TB drug and has intermediate hepatotoxicity risk; reintroduce first, then Isoniazid, then Pyrazinamide (most hepatotoxic — often not rechallenged)

Sequential reintroduction after TB DILI follows the principle of reintroducing the most effective drugs first: Rifampicin → Isoniazid → Pyrazinamide (if rechallenged at all). Each drug is reintroduced at full dose with LFT monitoring every 3 days. If LFTs rise >5× ULN or symptoms recur, that drug is identified as the culprit and permanently stopped. Pyrazinamide is the most common cause and is often not rechallenged — the continuation phase is extended to compensate.

Reference: NICE NG33 2016 – TB; BTS 2024 – TB DILI; ATS/IDSA 2003