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TUBERCULOSIS PRESCRIPTION / MEDICATION REQUEST FORM

TUBERCULOSIS PRESCRIPTION / MEDICATION REQUEST FORM 2025

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The document is a prescription and medication request form for the Alaska Tuberculosis Program, detailing the process for requesting tuberculosis medications. It includes patient information, medication details, dosing guidelines, and compliance with health regulations. The form emphasizes the importance of complete submissions to avoid processing delays and outlines specific drug regimens for treating tuberculosis in both adults and children.

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What is a medication request form?

Instructions: This form is to be used by participating physicians and providers to obtain coverage for a formulary drug requiring prior authorization (PA), a non-formulary drug for which there is no suitable alternative available, or any overrides of pharmacy management procedures such as step therapy, quantity limit

What are the 4 drugs used to treat TB?

Rifampin (RIF), Isoniazid (INH), Pyrazinamide (PZA), and. Ethambutol (EMB)

What are the 4 antibiotics for TB?

For initial empiric treatment of TB, start patients on a 4-drug regimen: isoniazid, rifampin, pyrazinamide, and ethambutol. Once the TB isolate is known to be fully susceptible, ethambutol can be discontinued.

What are the 5 medications for tuberculosis?

Table 5.1Drugs used in the treatment of tuberculosis DrugAdult dose mg/kg (range); [maximum dose] Group 1: first-line oral drugs Ethionamide (Eto) 1520 mg/kg [1000 mg] Prothionamide (Pto) 1520 mg/kg [1000 mg] Terizidone (Trd) 1520 mg/kg [900 mg]25 more rows

What is the 4R regimen for TB?

4R = 4 months of rifampicin; 9H = 9 months of isoniazid; CI = confidence interval. Active TB was diagnosed in one participant of the 4R arm (rate: 0.09/100 person-years, equivalent to 0.21 over the 28-month period) and four in the 9H arm (rate: 0.36/100 person-years, equivalent to 0.83 over the 28-month period).

What are the 4 TB medications?

Rifampin, isoniazid, pyrazinamide, and ethambutol are first-line antitubercular medications, which are FDA-approved and indicated for the treatment of Mycobacterium tuberculosis infections.

What is the prescription for tuberculosis?

The 4-month TB treatment regimen (high-dose daily rifapentine with moxifloxacin, isoniazid, and pyrazinamide) and 6-month RIPE (rifapentine, isoniazid, pyrazinamide, and ethambutol) regimen have unique considerations. The below table compares the recommended evaluation and testing considerations for the two regimens.

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