Interaction of Side Effects of Second Line TB Drugs Therapy in MDR-TB: Ethionamide- induced Hypothyroid and Cycloserine-induced Depression Episode Try Nirmala Sari 1 , Sumardi 2 , Heni Retnowulan 2 , Barmawi Hisyam 2 , Bambang Sigit Riyanto 2 , Eko Budiono 2 , Ika Trisnawati 2 1 Resident of Department of Internal Medicine, FK UGM/RSUP Dr. Sardjito Yogyakarta 2 Division of Pulmonology, Department of Internal Medicine, FK UGM/RSUP Dr. Sardjito Yogyakarta ABSTRACT Background: Second line anti tuberculosis drug in MDR-TB patients is notorious for having several side effects. Ethionamide is anti tuberculosis drug that is used as a second line therapy in MDR-TB patient management. Hypothyroid is an important side effect in ethionamide administration. Cycloserine is in the fourth group of second line therapy that acts as bacteriostatics. Psychiatric side effects such as anxiety, hallucination, depression, euphoria, habit alteration, and suicide are reported in 9,7%-50% of patients in cycloserine therapy. Case Presentation: A 46 year-old lady with MDR-TB started her second line anti TB drugs therapy since January 2016. Her regimen included levofloxacin, cycloserine, ethionamide, pyrazinamide, ethambutol and PAS (Para- Aminosalicylic Acid). Therapy evaluation in the first month control founded fatigueness, reduced communication, self-secluding, and behaviour alteration. Patient often felt sad, desperate, and had a lot of thought on her illness. Patient also had thoughts of suicide. Patient was then hospitalized and was diagnosed by psychiatry department with TB drugs -possibly cycloserine-induced depression episode. Then, cycloserine therapy was stopped. And at the same time, laboratory result showed an increase in TSH without hypothyroid symptoms. Levothyroxin 1x100 mcg was administered. In the third month of therapy, patient returned with a much higher TSH level, then ethionamide was stopped for 3 months. Evaluation was conducted post ethionamide cessation and found well-controlled TSH level. Ethionamide was then continued with titration doses per month. Conclusion: In MDR-TB therapy, potential complication of ethionamide administration should be considered carefully. Severe neurotoxicity caused by cycloserine can be managed by delaying the drug use temporarily. It is also worth considered that hypothyroid state can exhibit depression symptoms therefore careful monitoring of the side effects of anti TB drug therapy is needed. Keywords: Multi drug resistant, tuberculosis, drug-induced hypothyroid, drug-induced psychosis. ABSTRAK Latar Belakang: Pengobatan TB lini kedua pada pasien TB MDR diketahui memiliki beberapa efek samping. Etionamid adalah salah satu obat dalam pengobatan TB MDR lini kedua. Hipotiroid merupakan efek samping dari pemberian etionamid. Sikloserin merupakan salah satu dari komponen pengobatan lini kedua yang bersifat bakteriostatik. Efek samping psikiatri seperti ansietas, halusinasi, depresi, euforia, perubahan kebiasaan, dan bunuh diri dilaporkan sebanyak 9,7-50% pada pasien yang menjalani pengobatan dengan sikloserin. Presentasi kasus: Seorang perempuan berusia 46 tahun dengan diagnosis TB MDR, menjalani pengobatan TB lini kedua sejak Januari 2016. Regimen pengobatan terdiri dari levofloksasin, sikloserin, etionamid, pirazinamid, etambutol, dan PAS. Evaluasi pengobatan di bulan pertama menunjukkan adanya lelah, komunikasi yang berkurang, dan perubahan perilaku. Pasien sering merasa sedih, putus asa, dan sangat memikirkan penyakitnya. Pasien juga berpikir untuk mengakhiri hidupnya. Kemudian pasien menjalani rawat inap dan didiagnosis sebagai depresi imbas pengobatan TB, kemungkinan disebabkan sikloserin. Kemudian, pemberian sikloserin dihentikan. Dalam waktu yang bersamaan, pemeriksaan laboratorium menunjukkan adanya peningkatan TSH tanpa disertai gejala klinis hipotiroid. Dilakukan pemberian levotiroksin sebesar 1x100 mkg. Pada akhir minggu ke-3 pengobatan, kadar TSH tetap meningkat sehingga pemberian etionamid dihentikan selama 3 bulan. Evaluasi setelah penghentian pemberian etionamid menunjukkan kadar TSH terkendali. Pemberian etionamid kemudian dilanjutkan dengan dosis titrasi per bulan. Simpulan: Pada pengobatan TB MDR, timbulnya efek samping pemberian etionamid perlu diperhatikan. Neurotoksisitas berat yang disebabkan sikloserin dapat ditangani dengan penundaan pemberian obat sementara. Correspondence: dr. Try Nirmala Sari Email: try.nirmalasary@gmail.com Indonesian Journal of Hal lain yang perlu diingat adalah kondisi hipotiroid dapat memperlihatkan gejala depresi. Oleh karena itu, pemantauan terhadap efek samping obat TB diperlukan. Kata kunci: Multi drug resistant, tuberkulosis, hipotiroid imbas obat, psikosis imbas obat 106 CHEST Critical and Emergency Medicine Vol. 3, No. 3 Jul - Sept 2016