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How to handle the side effects of TB medication?

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Posted on Tue, 26 May 2015
Question: Hi mam
In continuation with my previous chat(I had a cesarean deivery in nov 14 and was suspected of tb) would like to have further queries to be guided by u

Have strted empirical att 23 days back.mantoux was 11 mm at 72 hour
Igra was o.81 positive
Ada 9.2
Usg..hypoechoucctrack of 14 mm
Based on igra usg and mrithat was doubtful of pid i have been put on empirical att for last 25days.
1
Mam pls detail ,e evrything about att,wen it is to be taken ,how is to be taken ,diet to be followed and how to encounter the side effects.
2
Doc i have also taken tayo 60 k once weekly six times till now,but while taking this att medicines i feel very weak tired and feverish during the day as if so eone has extracted all my power.is it common,with ceackling sounds feom my bones and body and headache too withblurred visison
3 mam how long does att take time to show its effects,right now i m given akt 4 witbevon folvite sorbilin and hifinac p or xinase d sos and rabonik plus or pan d softeron z and montair lc and soventis dc
I weigh 66 kg ..i take rifampicin beforebreakfast and rest of medic8nes post breakfast

Do theyneed to be taken same time exact daily or theybecome drug resistant
Is tht so..u have also seen the attached list of medicines taken by me sofar have my become drug resostant

4,doc if i have the soft tossue track,lesion or adhesion (whether tubercular or not as i m still confused )will att work on that.or will that track needs to be excsied sugically
5..if a surgical intervention is neccesary am i the right candidate for rhat ,(given a history of lscs 5 months back,allergic asthma,weak abominal wall strength,low immunity,malnutrotion and if there is tb infection inside).WILL IT BE SAFE TO GET DIAGNOSTIC LAPRPSCOPYDONE and will it help in tht track removal or ,may be it will settle from att
6.can u suggest me some iron and calcium supplement if i need to take them..i have taken cipzen forte for 1.5month..should i continue or fiscontinue its use(if there is a scar yossue teack
7.i have difficulty passing motions too..what should i do

Mam pls guide i m very scared
doctor
Answered by Dr. Shanti Vennam (1 hour later)
Brief Answer:
Detailed below.

Detailed Answer:
Hello Ms. XXXXXXX

Thanks for writing to us.

I have gone through all the attachments. Here are my answers.

1. ATT or antituberculosis treatment can imply several combinations depending on the site and extent of the disease, the condition of the patient and side effects experienced. There can be Rifampicin and non Rifampicin regimes depending on the patient's response.

Since you have been prescribed the four-drug regime, Rifampicin is to be taken on empty stomach while the rest can be taken after food. The drugs may be spaced at regular intervals for example, take INH and Ethambutol after breakfast and Pyrazinamide after lunch. This is to lessen the side effects.

Regular monthly check ups are mandatory along with laboratory tests to look for blood profile, liver and renal function. Eye-related problems are encountered with Ethambutol and hence regular ophthalmic tests are necessary during treatment.

Please take fresh fruits, vegetables, adequate liquids, milk and milk products and diet rich in protein. Adequate rest is also essential for a quick recovery.

2. Blurred vision should be attended to immediately and medication adjusted accordingly. The malaise felt is usually general and alleviates slowly as you get adjusted to the medication.

3. Usually, you can expect some response from the second month onward and the prescribed duration of treatment is usually 6 months. It is always better to stick to a regular plan while taking medication. This is to provide regular medication so as to avoid resistance, if the drug is missed. Please do not worry, you have not become drug resistant. The medications prescribed are mostly supplementary.

4. The need to get surgical excision can be contemplated at a later date when your ATT is complete. As a rule, except emergency procedures, no elective manipulations are done during ATT.

5. You need not think of planning a diagnostic laparoscopy now since you are under treatment as I mentioned earlier. This can be done at a later date if your symptoms do not abate. Fitness should not be a big problem if tackled properly.

6. Since you are already on iron supplement, you may continue with that. Any calcium supplement will do. Please stop Cipzen forte.

7. Please increase the dietary fiber. You may also use lactulose for easy passage of stool.

Hope your query has been clarified. Please feel free to contact for further information. I will be happy to help.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shanti Vennam (6 hours later)
Thank you so much for the detailed reply

I have been put on empirical att..but doc i still have some confusion regarding my correct diagnosis that whether mybproblem is because of pid ,tb or soft tissue track ,adhesions.

I know my question can bother u but pls i m very confused as despite taking medicines for last 25 days i m not getting much of relief.if my trck was indeed tu ercular( or not dont know)why the medicines are not showing effect,in fact the side effects are even bothersome

Is that possible mam that my track has turn necrotic after such a period of time as it was delayed in diagnosis and surgical excision is the only option left and if it t is so pls answer my point no 5 of erlier query.mybsurgeon has asked to wait for six weeks else will g0 for cect or diagnostic laproscopy

Mam plslet me know if it canbe cancerous problem like thing that has been missed off..how can i clear my dileema that if it is some cancerous lesion or not,had 8t been cancerous would it have been possible to see it on mri or usg or amyblood work..pls guide doc..my health is not getting better ..i wanr to ensure that it is not cancerous.is there any non invasive procedure to ensure that it is not cancer

I takeduplaac and sos naturolax forr motions for a long time is it safe nd for calcium can i take supracal and for iron orofer xt..pls suggest me some gud pre and probiotoc that can be taken with att

Can ayurvedic herbal med like liv 52 immunocare and herbocalcium also be taken with att..pls guide
doctor
Answered by Dr. Shanti Vennam (6 hours later)
Brief Answer:
Cannot be cancerous.

Detailed Answer:
Hi,

Thanks for writing back.

It is true that you have been put on ATT based on the tests and the finding of pelvic adhesions. The fact that you do not feel any better with treatment could be due to the side effects you are facing with the drugs. If you feel there is some lessened pain, then the drugs are indeed working.

The cause of the adhesions, when they have occurred, whether they were present prior to the cesarean also, can be deduced well by the consultant who attended on you during your pregnancy and surgery. So many times, simple postoperative adhesions occur for which no causative organism can be held responsible and this also depends on the tissue reaction of the individual patient.

The lesion is less likely to become necrotic. If so, you would notice it in investigation and also clinically. It is also very unlikely to be cancerous. You can have a biopsy of the lesion to exclude all fears.

Duphalac and naturolax are safe provided you do not overuse them. It is always better to train the bowel for a proper natural reflex. There are some exercises in yoga meant to relieve constipation. I think you can try them.

The supplements you are currently taking are good enough. You can take plenty of fresh fruit and vegetables to provide you with all essential nutrients. You can take Sporlac as a probiotic.

Hope your query has been answered. Please feel free to ask any more questions. I will be glad to help.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Shanti Vennam (40 hours later)
Thanks doc.

The pain is bit better now.for a day i feel its getting better,other time tht comes out to be same..apart from pain doc its the heaviness in my lower abdomen that is bothering me now the lower abdomwn feels heavy while coughing sneezing or laughing or turning as if somerhing is pushing or m8ving inside the morw discomfort is on left lower quadrant below navel and above scar.till the time i take meals it feels as if things are getting accumulated there and wen motions arevpassed that sweelling and discomfort reduces a bit ,but after some time wen again i take meals that bump forms again,,for this reason not able to take my diet properly
Can that be starting of incisional hernia(as told by one of my radiologist)
Yes doc i have started doing yoga.not able to do much exercise ,,doing daily activoties also,but feels lot of backache and bodyche like crackng sound from my body,I was also siggested hifenac p or mr sos if there is severe pain.mam what pain killer or muscle relaxant is safe with att is hifinac mr safe.i feel i have become a godown of medicines

My gynae who operated on ,e doesnot remember anything,,she is in a opinion that she does lots of surgery on daily basis

I didnt have constipation before or during pregnancy very much.just had problem of asthma before and during pregnancy and yes twice or thrice i had uti in pregnancy

If that track would have been necrotic how would have that come in clinically ans seen on investigations..Mam i have heard regarding a blood test of ca 125 ..what does that test denotes..may be that track is not cancerous,but i want to clear my doubta

Does these side effects of att happens with everyone or its with me only

Does taking att will help in the pelvic adhesions also whether tubercular or not
Have i took a right decision by starting att..i doubt might beproblem is somethong else and i m taking medic7nes for something else

Pls guide..does taking probiotics like darolac or sorbiline creates c8nstipation.for how long sorbiline can be taken
.
doctor
Answered by Dr. Shanti Vennam (11 hours later)
Brief Answer:
Anti-inflammatory drugs can be reduced.

Detailed Answer:
Hello,

Thanks for writing again.

I can understand your agony.

If you suspect incisional hernia, a clinical examination by a surgeon followed by scanning (which you already had), will help to come to a conclusion. Laxity of the abdominal wall subsequent to the delivery also should be considered. Hernia in a transverse lower abdominal scar is indeed, a rare finding. Some scar induration can be had for a few months after the surgery. The nerve endings which have been cut during the procedure also create vague pains as they heal. Use of enzymes is often done in order to help healing of a scar.

Yoga is supposed to be regular practice to help heal the body and mind to attain fitness in course of time. Never mind if you cannot do it well now, patience and perseverance will train your body in due time. No one can do everything from day one.

It is better to reduce use of anti-inflammatory agents as they have unwanted side effects on prolonged use. Since the combination you are using has Aceclofenac, I would suggest going for some combination of paracetamol and muscle relaxant without this drug.

Necrotic tissue images differently from normal tissue and also you would have some systemic findings like fever, general malaise etc.

CA 125 is a tumor marker test to detect certain cancers and for post-treatment monitoring and also to detect ovarian cancer at the earliest or those with the risk.

You need not worry about the track being cancerous. If you doubt, as I had already mentioned, simple biopsy would suffice.

ATT has side effects; in fact, there are people who experience more severe side effects than you have. Though, the majority tolerate the medication well.

Since you have started the medication on an empirical basis, you cannot stop it half-way, but, have to wait until the course is over. Follow up blood tests and sonograms help to monitor the response. The adhesions resolve to a great extent, if this is the apt treatment. If you feel you are taking the wrong medication, please consult a specialist in infectious diseases to clarify.

Probiotics do not cause constipation. You can have them as long as you wish or until your doctor has prescribed.

Hope all your queries have been clarified. Please contact for further help. I will be glad to do so.

regards,
Shanti.V.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shanti Vennam (2 days later)
Thanks mam,

My pain is improving though the heaviness os nothering ,dont feel it is fat,it feels as of something os stuck..one of my radiologost said that because of weak abdominal wall and behining of inciosional hernia i m feeling the bowel movementswen my last usg was done 14 ays back
Doc sometimes i feel tingling and pinching numbness in my left body particullarly hand and my motions are restricting even taking duphalac and soferon ,,i feel dont get defectated properly i had my periods 1 week back.they were normal as in i didnt have much pain but post that above scar area on my left side more i feel something is stuck..can there be bowel obstruction because of this pelvic infection.

Mam i have a doubt of turning this track necrotic

Doc since my treatment was delayed for almost 4 months ,is it possible that if it is indeed tb,it has spread into other organs ,..for last three days my backache has increased and i feel itching and tingling in my body

I have also heard that att might cause hepatitis,,what would be preventive measures to check that earlier before happening

Nd mam if at all i need to go for diagnostic laproscopy(thought i want it to be tha last resort)does that further increaees problem of tubercular infection and further adhesions..and what are the usefulness of ahesion barriers like sprafilm and all.are they really effctive..can they be used in diagnostic laproscopy..do they help in future

Mam suppose i take medicines by 11 daily,and gor two three days i took them at 1 or 2 o clock..can change in this may also cause drig resistance (timimngs),..though i didnt miss a single dose one day..

Doc y cant i continue with enzyme serriatopeptidase ..i took it for 1.5 month is that the maximum limit

Can u pls suggest some good pain killer with muscle relaxant

Mam i have been on hell lot of medicines post delivery and antibiotics..my diet is also not supprting as i feel vomit and bl9ating and that hurts me more downside..what should i do..if my bowel moments are stuck gor last 3 4 days will it shpw in ultrasound

Pls guide

doctor
Answered by Dr. Shanti Vennam (2 hours later)
Brief Answer:
Detailed below.

Detailed Answer:
Hello,

Thanks for writing back.

Incisional hernia can be easily diagnosed through clinical examination, abdominal sonogram and an abdominal MRI. You may repeat the investigations if necessary.

ATT creates vitamin deficiency and to correct this, supplements are a must. Pyridoxine is to be added in additional amount. You could be experiencing vague neurological symptoms. The constipation is a result of inadequate fiber in the diet, absence of physical activity and also the medications being given.

Bowel obstruction is a possibility if a loop of bowel gets impacted and this calls for immediate attention. Pelvic infection is unlikely to cause this unless there is a strong reason for it.

If you strongly believe the track has become necrotic, you can undergo a biopsy.

With itching, you should get liver function checked. If drug-induced hepatitis has happened, it will subside in an otherwise healthy person if the causative drug is withheld.

Diagnostic laparoscopy is not advised when there are internal adhesions. Adhesion barriers are a complicated procedure and not useful in your case.

Slight variation in the timing of the medication, does not alter the drug course. No resistance develops thus.

You can have paracetamol,Iibuprofen and chlorzoxazone as per the instructions. Alternatively, you can also try Tizanidine.

Please seek help from a surgeon for proper evaluation. Further management can be planned accordingly.

Hope this helps.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Shanti Vennam (44 hours later)
Thanks for the reply and pls dont be sorry

Mam i hav3 gotmy blood work done tday..pls detail the abbrations in lft kftand specially crp,.can increase in crp because of my current health problem or is it because of some other reason like tissue injury or inflammation ..last month on 13 march it was 7.65.wen my esr has come down why there is still high value of crp..arewe still geosslymissing something or will it also settle slowly withatt..

Should intakezinase d again..i took it for 20 25 days in feb and ,arch which was floowed by serraptopeptidase alone for another 25 days cipzen forte..

Mam wen i started att i was taking rifampicin begore breakfast and rest of the thre post breakfast(in a span of 2 .3hours ,butnow i myself have changed it to rifampicn beforebreakfast followed by commim tablet of inh and ethambutol post breakfastamd pyranximide 1500 post lunch for last 1 week ..(i m taking akt4)
Can that causedrug resistance..can i take it lime this..

I hve started feeling vaginal itching also..for that i m using lactacyd twicw a day..is this becauseof antibiotics what can be done..pls guide..

What would be symptoms if there is bowel obstruction
doctor
Answered by Dr. Shanti Vennam (1 hour later)
Brief Answer:
Please monitor liver finction.

Detailed Answer:
Hi,

Thanks for writing back.

I have gone through the blood assay report. The hemogram is mostly normal. Serum electrolytes are normal. Thyroid function is normal. The lowered BUN or blood urea nitrogen levels could mean over-hydration, malnutrition, low protein diet or a compromised liver function.

Elevated ALT levels suggest impaired liver function perhaps secondary to medication. This needs a follow up and monitoring of liver function carefully since you are on ATT.

In the lipid profile, triglycerides are elevated and so is VLDL. This depends on the type of food consumed the day before the test too and the amount of exercise undertaken. This is not of much problem and can be corrected by simple dietary measures at your age.

The C-Reactive protein or CRP is elevated. This happens in any tissue injury leading to inflammation and is seen in tuberculosis. Falling titres could mean lessening of the inflammation.

The urine analysis is normal.

You can continue taking the ATT medication as you are following now. Drug resistance does not occur if you stick to regular intake of the medication, following instructions, be it whatever time.

Tuberculosis also creates decreased immunity and as a result you can also experience other infections simultaneously. If you have a vaginal itch, please do not self-medicate. Get a proper diagnosis and specific treatment.

I have given a link here for you to go through. This describes in brief intestinal obstruction. Hope this clears your doubts.

http://www.nlm.nih.gov/medlineplus/ency/article/000260.htm

Hope all your queries have been answered.

Wish you speedy recovery.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Shanti Vennam (2 days later)
Thanks mam,

For last two days ,i was having difficulty in passing motions so i took isabgoul husk,
Naturolax softvac 4 spoon simultaneoulsy..nd now feelung lot of discomfort in stomach as wen medicines were started for att..can overuse of laxative cause intentinal swelling tht i m feelung discomfort for last two days XXXXXXX the problem has returned

2.mam i started att on 1 .4.15,for 25 days i took rifampicin before breakfast and rest three post breakfast,.yes i m takung bendon 20 mg with akt 4..but post 25 april since i was having severe side effcects and malsise i adjusted the inrake of dose by takung rifampicin before breakfast and etehmbutol and isonizaid post breakfast and ptrnazimide 750 each after lunch..is that safe mam i know u ansewred this ,becouse i read somewhwre that they neccesarily have to be taken same time ,otherwise it can cause drug resiatance,....is tht really so..do theses medicines really have to be taken exactly at the same time on daily basis

Mam can cect show the reason for my abdominal discomfort,like tuberculosis or adhesions or intentinal sweeling or blockage..i m in my 5th week of att treatment..y do i feel ftereveryy two three days its returning ,,though pain is reduced,,sweeling still persists.more on left side and in a gap of some time it feels something is moving and touching my abdominal wall especially wen i cough sneeze or vomit or even lie straight on my left sid2 below navel..what could this denote..do i feel bowel movements and if yes y could they be so

Mam,pls guide me have i really taken a sound decision by starting att,or is it post cesrean healing or something else,,because i have discomfort but that doesnt come in blood work....

Is it normal to have this crp rate in tb infection..or does tht comes high in other abdominal or pelvic infections also..
doctor
Answered by Dr. Shanti Vennam (3 hours later)
Brief Answer:
Bowel distension caused by Isapgol is the likely cause.

Detailed Answer:
Hi Ms. XXXXXXX

Thanks for writing back.

Since you have taken all the three medications simultaneously, you seem to have developed bowel distension due to the Isapgol husk which is causing you this discomfort. You may have to wait without any further such medication for relief. Else, you may try taking a glycerine enema.

As I have already answered before, you can take the medications at any fixed time of the day, roughly. It does not matter if you miss the margin by an hour, but do not forget taking them everyday.

If you have repeated swelling of the abdomen that is increased with stress, you can get it examined by a physician or a surgeon to exclude hernia. If it is not so, it could simply be a lax fatty abdominal wall. Toning up would then become necessary.

CECT or contrast-enhanced computerized tomography can be more helpful in diagnosing upper abdomen conditions; for those in the pelvis, MRI and ultrasound are better. MDCT or multi-detector CT is helpful in detecting abdominal wall hernias clearly. Hypersensitivity and drug interference are the limiting factors for the use of CECT. You can have it, but, under strict supervision only.

To properly guide you if you are on the right track, you need a specialist in infectious diseases and I am not the person. I can only give you suggestions regarding your treatment schedule. If you have started the ATT after the suggestion of an expert, then perhaps you needed it. Only after six weeks of treatment, can some idea be obtained about the efficacy of the treatment.

C-reactive protein can remain elevated in any inflammation and there is no specific value that can be quoted to diagnose tuberculosis.

Hope all your queries have been clarified.

Wish you good health and speedy recovery.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Pradeep Vitta
doctor
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Follow up: Dr. Shanti Vennam (2 days later)
Thanks for reply

Mam pls tell my weight is67 kg and i am taking akt 4.is that the right amount as pe4 my weight

For how long thesemedicines can be taken
1.sofetron z..i took it for one month

2zinase d ..i took it for 25 days in feb and march then was swithched to cipzen forte which i took for another 15 20 days ,,now stopped for last 25 days, both however for pain killer occasionally my physician has given me with akt 4..can i use it again as i m observing sweeling in my left abdomen again..and if there is some sweeling or infection in intestines

3.sorbilin

4 rabonik plus an perinorm cd

Mam if at any chance i will need to go for cect can that be done with my att medicines or tht has to be stopped for a day or two or drug senstivity

Does att show its effect like thtonly,,for a day or two i feel things are improving but then again it resurfces or is itbecauseif lowdosageas as per my weight

I feel very hot sometimes with sweating too..is that also side effect of medicine

If at all i need to go for diagnostoc lap,,what all details abt the procedire safety and all needs to be asked from my foc regarding future complications safety amd all as it can caus3 furtheradhesions and priblems

Mam i heard somewhere that in case of pelvic tb,sometimes surgery is requored,,is tht so,,

Mam if thos is soft tossue track or scar tossue doea tht settle withatt,,or has to be surgically exsicised ,,for how long can scar tissue remain in body..i feel sweelung in my ovaroes what ar the symptoms

Pls guide in detail
doctor
Answered by Dr. Shanti Vennam (1 hour later)
Brief Answer:
Detailed below.

Detailed Answer:
Hi,

Thanks for writing back.

Here are your answers.

-The dosage of Ethambutol is 15 mg./kg. body weight in your case.

-The dosage of Pyrazinamide is 1500 mg. per day for your body weight.

-The dosage of INH is 300 mg. per day or 15 mg. /kg. body weight.

-The dosage of Rifampicin is 10 mg./kg. body weight.

So, you can calculate the dosage you are receiving and if is is on the lower side.

Softeron Z is a nutritional supplement and can be so long as you are under treatment and also later if your general condition warrants it.

You need not use enzymes for prolonged periods, if there is no tissue reaction detected. You can use analgesics as and when needed. If you are feeding the baby, please be careful with the medications being used.

Sorbilin can be used until you are on ATT.

Rabeprazole can be used as long as you are on ATT sine some amount of gastritis is expected with the medication; so is the need to use Perinorm CD.

Usually, invasive procedures are avoided while ATT is being given as immunity is low and infections are common. Since it is an outpatient procedure, you can go for it with your routine medication on, but only with the operating doctor's knowledge. Also, since the procedure of CECT involves XXXXXXX you should be aware that drug interactions and sensitivity can develop.

Your perception of well being can depend on the physiology of the body as well as the psychology. ATT does not show variable effects; in fact, steady improvement is often seen. The dosages are mostly suited to your weight. Please remember, overdose of ATT medication can lead to toxic effects. Your hot flushes also can be related to the weather, your hormones, medications etc.

I have attached a link here about the procedure, preparation and precautions to be taken while getting a diagnostic laparoscopy done. Please go through to clarify your doubts.
http://www.nlm.nih.gov/medlineplus/ency/article/003918.htm

Surgery is required when there is some obstruction, mass formation with no resolve after complete treatment, infertility which may need correction and so on. Since you have a doubtful track only, you may not need any surgery at all.

You cannot feel the swelling in your ovaries unless you have ovarian cysts with complications or if the capsule of the ovary is stretched. As I mentioned earlier, you have to wait for at least 6 weeks to note response to treatment. Further management can be planned after completion of the course.

Hope I have answered in detail.

Wish you good health.

regards,
Shanti.V.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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How to handle the side effects of TB medication?

Brief Answer: Detailed below. Detailed Answer: Hello Ms. XXXXXXX Thanks for writing to us. I have gone through all the attachments. Here are my answers. 1. ATT or antituberculosis treatment can imply several combinations depending on the site and extent of the disease, the condition of the patient and side effects experienced. There can be Rifampicin and non Rifampicin regimes depending on the patient's response. Since you have been prescribed the four-drug regime, Rifampicin is to be taken on empty stomach while the rest can be taken after food. The drugs may be spaced at regular intervals for example, take INH and Ethambutol after breakfast and Pyrazinamide after lunch. This is to lessen the side effects. Regular monthly check ups are mandatory along with laboratory tests to look for blood profile, liver and renal function. Eye-related problems are encountered with Ethambutol and hence regular ophthalmic tests are necessary during treatment. Please take fresh fruits, vegetables, adequate liquids, milk and milk products and diet rich in protein. Adequate rest is also essential for a quick recovery. 2. Blurred vision should be attended to immediately and medication adjusted accordingly. The malaise felt is usually general and alleviates slowly as you get adjusted to the medication. 3. Usually, you can expect some response from the second month onward and the prescribed duration of treatment is usually 6 months. It is always better to stick to a regular plan while taking medication. This is to provide regular medication so as to avoid resistance, if the drug is missed. Please do not worry, you have not become drug resistant. The medications prescribed are mostly supplementary. 4. The need to get surgical excision can be contemplated at a later date when your ATT is complete. As a rule, except emergency procedures, no elective manipulations are done during ATT. 5. You need not think of planning a diagnostic laparoscopy now since you are under treatment as I mentioned earlier. This can be done at a later date if your symptoms do not abate. Fitness should not be a big problem if tackled properly. 6. Since you are already on iron supplement, you may continue with that. Any calcium supplement will do. Please stop Cipzen forte. 7. Please increase the dietary fiber. You may also use lactulose for easy passage of stool. Hope your query has been clarified. Please feel free to contact for further information. I will be happy to help. regards, Shanti.V.