A 28-year-old client is starting rifampin as part of multi-drug therapy for active tuberculosis. The client also takes a combined oral contraceptive. Which client teaching is most important?

Rifampin (Rifadin) is a key bactericidal agent in tuberculosis multi-drug therapy (RIPE: rifampin, isoniazid, pyrazinamide, ethambutol) and is also used for prophylaxis in N. meningitidis and H. influenzae contacts. It is a potent inducer of CYP3A4, CYP2C9, CYP1A2, P-glycoprotein, and other metabolic enzymes, leading to dramatic reductions in plasma concentrations of many drugs. Important teaching: (1) orange-red discoloration of body fluids — urine, sweat, tears, saliva, breast milk — is a benign expected finding and not jaundice; warn the client and family so they are not alarmed; soft contact lenses can be permanently stained — recommend glasses or rigid lenses during therapy; (2) reduced contraceptive efficacy — combined oral contraceptives, the patch, and the ring all lose efficacy; recommend nonhormonal backup such as condoms during therapy and for at least 28 days after rifampin discontinuation; the levonorgestrel IUD or copper IUD is preferred long-term; (3) drug interactions — warfarin (INR drop), antiretrovirals (especially HIV protease inhibitors and NNRTIs), tacrolimus and cyclosporine (rejection), methadone (withdrawal), corticosteroids, oral hypoglycemics, and many others — review all home meds with pharmacist; (4) hepatotoxicity — report jaundice, dark urine, RUQ pain, persistent nausea or anorexia; baseline LFTs and periodic monitoring; (5) flu-like syndrome and thrombocytopenia with intermittent dosing; (6) take on empty stomach for absorption when possible. Stopping for orange urine, alcohol, and crushing are wrong.

Orange-red body fluids are harmless; CYP induction lowers OCPs and many drugs. Backup contraception 28 days after stopping. The orange tears and contact-lens staining are NCLEX favorites.