Ethionamide is a second line drug in the therapy of tuberculosis used only in combination with other agents and for drug-resistant tuberculosis. Ethionamide has been linked to transient, asymptomatic elevations in serum aminotransferase levels and in uncommon instances of acute liver injury, which can be severe.


Ethionamide (eth" eye on' a mide) is a thio-isonicotinamide somewhat similar in structure to isoniazid. Ethionamide is a prodrug and, like isoniazid, requires activation whereupon it inhibits mycobacterial fatty acid synthesis (enoyl-ACP reductase) that is necessary for cell wall synthesis and repair. Interestingly, there is little cross resistance between isoniazid and ethionamide, probably because they are activated by different mycobacterial enzymes, and therefore can be used together. Ethionamide is currently used only as a secondary agent in the treatment of active tuberculosis, always in combination with other antituberculosis agents such as isoniazid, ethambutol, pyrazinamide and/or rifampin and usually for multidrug resistant mycobacterial infections or in situations where first line agents are contraindicated. Ethionamide also has activity against lepromatous leprosy. Ethionamide is available as 250 mg tablets in generic forms and under the brand name Trecator. The typical dose in adults is 250 mg twice daily, but can then be increased gradually to a total dose of 15 to 20 mg/kg per day to a maximum of 1 gram given either once or in two divided doses daily. Pyridoxine (vitamin B6: 50 mg daily) is usually administered with ethionamide. Common side effects include gastrointestinal upset, nausea, anorexia, diarrhea, metallic taste, stomatitis, depression, drowsiness and fatigue. Severe adverse events include mycobacterial resistance, hypersensitivity reactions and severe cutaneous reactions including Stevens Johnson syndrome, toxic epidermal necrolysis and DRESS syndrome.

The management of multidrug resistant tuberculosis is challenging and should be under the direction of physicians with expertise in tuberculosis therapy and management of its side effects. Optimal regimens of therapy for tuberculosis are complex and change frequently. Regularly updated recommendations on use of drugs for tuberculosis, including indications, contraindications, warnings, dosages and monitoring recommendations are available at the Centers for Disease Control and Prevention website: http://www.cdc.gov/tb/publications/guidelines/Treatment.htm.


Ethionamide therapy has been linked to elevations in serum aminotransferase levels in a proportion of patients, but these elevations are typically self-limited and asymptomatic. More importantly, ethionamide has been linked to many instances of clinical apparent acute liver injury that arise in up to 5% of patients and can be severe and even fatal. The time to onset and clinical features of hepatic injury due to ethionamide resemble those of isoniazid, the latency ranging from 2 weeks to more than 6 months after starting (most arise within 1 to 3 months), and the pattern of enzyme elevations typically being hepatocellular and resembling acute viral hepatitis. Features of hypersensitivity (rash, fever and eosinophilia) are uncommon. Like isoniazid, ethionamide therapy may be associated with development of autoantibodies (typically ANA), but titers are generally low and rarely accompanied by autoimmune conditions. Cases of severe hypersensitivity reaction including Stevens Johnson Syndrome and DRESS which can be accompanied by liver injury have been described with ethionamide.

Likelihood score: B (highly likely although rare cause of clinically apparent liver injury).

Mechanism of Injury

Ethionamide is extensively metabolized by the liver and liver injury likely is due to a toxic or immunologically active intermediate. Rapid recurrence of injury upon rechallenge suggests a hypersensitivity reaction.

Outcome and Management

Serum aminotransferase elevations during ethionamide therapy are generally transient and asymptomatic, but elevations accompanied by symptoms of hepatitis and those above five times ULN should lead to prompt discontinuation. Monitoring of serum aminotransferase levels is indicated in patients with underlying liver disease receiving ethionamide and in those with a high risk of developing hepatotoxicity. Some cases of ethionamide hepatotoxicity have been severe and fatal instances have been reported. Cross reactivity to hepatic injury between isoniazid and ethionamide has not been shown, and several patients with clinically apparent liver injury due to ethionamide have later tolerated isoniazid without difficulty.

[First line medications used in the therapy of tuberculosis in the US include ethambutol, isoniazid, pyrazinamide, rifabutin, rifampin, and rifapentine. Second line medications include streptomycin, capreomycin, cycloserine, ethionamide, pretomanid, fluoroquinolones such as levofloxacin and moxifloxacin, aminoglycosides such as amikacin, and para-aminosalicylic acid (PAS).]

Drug Class: Antituberculosis Agents

Other Drugs in the Class: Bedaquiline, Capreomycin, Cycloserine, Ethambutol, Isoniazid, Pretomanid, Pyrazinamide, Rifabutin, Rifampin, Rifapentine, Streptomycin



Ethionamide – Trecator®


Antituberculosis Agents


Product labeling at DailyMed, National Library of Medicine, NIH



References updated: 16 December 2020

Abbreviations: DRESS, drug rash with eosinophilia and systemic symptoms; HIV, human immunodeficiency virus; MAC, Mycobacterium avium complex; PAS, para-aminosalicylic acid; SJS, Stevens Johnson syndrome; TEN, toxic epidermal necrolysis.

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