한국인 폐결핵환자의 화학치료에 관한 임상적 연구

Abstract

Recent advances in the treatment of tuberculosis especially chemotherapy has

brought a considerable change in the concept of this dreadful diseases. Before the

era of chemotherapy, rest was considered the most important portion of the

treatment of pulmonary tuberculosis. However, since the introduction of effective

drugs the value of rest has apparently decreased. Thus it causes less econimic

burden for the care of tuberculosis individually as well as nationally. it is

particularly significant in these areas where sufficient hospital facilities are

not available for all discovered active pulmonary tuberculosis patients.

This paper is to report the results of investigation on the ambulatory

chemotherapy for 676 active pulmonary tuberculosis patients and the clinical

effects of various regimens of combined major drugs. for regimens of chemotherapy

have been employed: 1. Streptomycin isoniazide 98 patients(14.6 per cent), 2.

Streptomycin-PAS 168 patients(25 per cent) of total treated patients, 3.

PAS-isoniazide 380 patients(56 per cent), 4. Twenty-one patients also received

triple frug combination treatment in consideration of the seriousness of the

disease. The isoniazide alone was nine patients(1.3 per cent). An analysis of the

results of treatment was made according to the clinical status of the disease and

these results were compared indetail according to the various drug regimens used.

The majority(87 per cent) of above patients who have visited the clinic showed

moderately or far advanced disease and more than half of the patients received

chemotherapy regularly or irregularly before they visited clinic. A comparative

study of different combined regimens as to bacteriological and reentgenelogical

results before and after chemotherapy revealed that the Sm-PAS regimen was less

effective them PAS-INH or SM-INH regimens. The results of triple drug therapy

indioated for the relatively advanced patients has not particulary better than the

combined use of two drugs aforementioned probably due to the higher resistance of

organisms developed after full-term chemotherapy. The negative conversion rate of

sputum after 12 and 24 months chemotherapy on ambulatory basis has been 35.8 and

47,3 per cent respectively and the improvement appeared to continue even after 12

months has not show any significant improvement on x-ray findings. However, the

rate of inactivation of disease after 12 and 24 months chemotherapy has each been

14 and 26 per cent, and this continued improvement, despite the standstill

situation on the x-ray, can be attributed to the continuing improvement in the

negative conversion rate of sputum. The overall rate of the inactivation of the

long-term chemotherapy tried for the Korean pulmonary tuberculosis patients on

ambulatory basis has definitely been poorer than that of the hospitalized patients

or ambulatory patients in other advanced countries.

Perhaps the main reason of the above poorer result is the disadvantageous

socio-economic factors in this country which do not permit these patients the

necessary rest and ample nourishment. More than half of the minimal cases (53 and

71 per cent) have been in activated in 12 and 24 months, but the prognosis if the

moderately or far advanced patients have generally been poor. And the cure of the

severe cases appears to be almost impossible on ambulatory basis. However, the fact

that 35.8 and 47.3 per cent of the open pulmonary tuberculosis cases become

non-infections in 12 and 24 months as a result of the long-term chemotherapy seem

to show the usefulness of this ambulatory treatment from the view point of public

health. In view of the limitation of ambulatory chemotherapy, the selection of the

subject had better be limited to minimal or reversible cases. The end of 12 months'

chemotherapy appears to be an important turning point in the re-evaluation of the

patients' prognosis whether to be remained in continued chemotherapy, surgical

intervention or other measures.

Part Ⅱ. The Clinical Effects of Newer Anti-tuberculous Agent and Special Use of

Drugs.

Kiho Kim, M.D.

Department of Internal Medicine Yonsei University Medical School

(Directed by Prof. Kwang Hun Cho)

Since the advancement of anti-tuberculous chemotherapy by the development of SM,

PAS and INH, most of the active pulmonary tuber-oulosis have been almost

successfully treated by the combined use of three major drugs, especially by a

long-term chmotherapy. However, the application of Major drugs which are widely

used has a certain limitation of their actions. The emergence of bacterial

resistance induced by the long-term chemotherapy increases the number of patients

whose therapeutic effect cannot be expected from the use of ordinnary drugs. Some

of these cases are probably too far progressed to be effective and the others who

have become ineffective to these drugs due to inadequate and irregular drug therapy

previously. Therefore, new agents which have no cross-resistance with the major

drugs and have a stronger beateriocidal action have been widely sought.

Author has already discussed the clinicial effects of combined chemotherapy using

major drugs in previous chapter. This paper is to report the clinical effects of

newer anti-tuberculous angents such as Cycloserine, Nicotinaldehyde

thiosemicarbasone, a massive use of isaniazide and an combined therapy with Steroid

hormone in this chapter.

The combined therapy of Cycloserine-isoniazid (10 cases), massive isoniazid

therapy (10 cases), and Steroid hormone therapy (9 cases) for the relatively

advanced chronic pulmonary tuberculosis patients; and the combined therapy of

Nicotinal-dehyde thiosemicarbasone-isoniazid for ten patients who have no previous

chemotherapy hae been tried. An analysis of the results of trestment was made

according to the clinical status of the disease, and these results were compared in

detail according to the various drug regumens used.

A clinical study on the effect of these treatments has been made and the

following results were obtained. At the and of 6 months Cycloserine-isoniazid

combined therapy, 3 cases out of 10 showed negative conversion of sputum and 4

cases showed improvement of the lesions and diminution of cavity size in the x-ray

findings. During the course of the treatment, no scrious side reactions have been

noted and it appears that the combined use of Cycloserine 0.5 gm daily and

Isoniazid can be safely employed for the ambulatory patients.

The combined therapy of Nicotinaldehyde thiosemicarbasone-isoniazid after 6

months' period resulted in 40% of negative conversion of sputum and 73.9% of x-ray

improvement after 6 months ambulatory treatement. The daily dosage of 300 mg of

this preparation has shown no marked side reactions.

The result of the massive Isonizid (approximately 1000 mg daily combined with

pyridoxine hydrochloride (100 mg daily) after 6 months therapy has shown only

slight improvement in the x-ray and negative conversion rate of sputum. However,

there has been a fairly marked imrovement of the subjective symptoms. The

peripheral neuropaty, the anticipated toxicity of Isoniazid, was not seen in the

course of this therapy.

The short-term follow-up study of Steroid hormone combined chemotherapy under the

least available chemically sheltered condition revealed on single case of negative

conversion of sputum but moderate improvement in x-ray findings. Evident appearance

of the acne-type eruptions has been seen in 7 out of 9 cases at a result of the

hypercortism due to Sterbid hormone.