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Maranchick NF, Kwara A, Peloquin CA. Clinical considerations and pharmacokinetic interactions between HIV and tuberculosis therapeutics. Expert Rev Clin Pharmacol 2024; 17:537-547. [PMID: 38339997 DOI: 10.1080/17512433.2024.2317954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious disease cause of mortality worldwide, especially for people living with human immunodeficiency virus (PLWH). Treating TB in PLWH can be challenging due to numerous drug interactions. AREAS COVERED This review discusses drug interactions between antitubercular and antiretroviral drugs. Due to its clinical importance, initiation of antiretroviral therapy in patients requiring TB treatment is discussed. Special focus is placed on the rifamycin class, as it accounts for the majority of interactions. Clinically relevant guidance is provided on how to manage these interactions. An additional section on utilizing therapeutic drug monitoring (TDM) to optimize drug exposure and minimize toxicities is included. EXPERT OPINION Antitubercular and antiretroviral coadministration can be successfully managed. TDM can be used to optimize drug exposure and minimize toxicity risk. As new TB and HIV drugs are discovered, additional research will be needed to assess for clinically relevant drug interactions.
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Affiliation(s)
- Nicole F Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Awewura Kwara
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
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Metcalfe JZ, Economou T, Naufal F, Kucukosmanoglu M, Kleiman R, Phillips PPJ, Conradie F. Validation of a Handheld 6-Lead Device for QT Interval Monitoring in Resource-Limited Settings. JAMA Netw Open 2024; 7:e2415576. [PMID: 38848063 PMCID: PMC11161846 DOI: 10.1001/jamanetworkopen.2024.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/08/2024] [Indexed: 06/10/2024] Open
Abstract
Importance Rifampin-resistant tuberculosis treatment regimens require electrocardiographic (ECG) monitoring due to the use of multiple QTc-prolonging agents. Formal 12-lead ECG devices represent a significant burden in resource-constrained clinics worldwide and a potential barrier to treatment scale-up in some settings. Objective To evaluate the diagnostic accuracy of a handheld 6-lead ECG device within resource-constrained clinics. Design, Setting, and Participants This diagnostic study was performed within a multicenter, pragmatic (broad eligibility criteria with no exclusions for randomized participants), phase 3 rifampin-resistant tuberculosis treatment trial (BEAT Tuberculosis [Building Evidence for Advancing New Treatment for Tuberculosis]) in South Africa. A total of 192 consecutive trial participants were assessed, and 191 were recruited for this substudy between January 21, 2021, and March 27, 2023. A low proportion (3 of 432 [0.7%]) of all screened trial participants were excluded due to a QTc interval greater than 450 milliseconds. Triplicate reference standard 12-lead ECG results were human calibrated with readers blinded to 6-lead ECG results. Main Outcomes and Measures Diagnostic accuracy, repeatability, and feasibility of a 6-lead ECG device. Results A total of 191 participants (median age, 36 years [IQR, 28-45 years]; 81 female participants [42.4%]; 91 participants [47.6%] living with HIV) with a median of 4 clinic visits (IQR, 3-4 visits) contributed 2070 and 2015 12-lead and 6-lead ECG assessments, respectively. Across 170 participants attending 489 total clinic visits where valid triplicate QTc measurements were available for both devices, the mean 12-lead QTc measurement was 418 milliseconds (range, 321-519 milliseconds), and the mean 6-lead QTc measurement was 422 milliseconds (range, 288-574 milliseconds; proportion of variation explained, R2 = 0.4; P < .001). At a QTc interval threshold of 500 milliseconds, the 6-lead ECG device had a negative predictive value of 99.8% (95% CI, 98.8%-99.9%) and a positive predictive value of 16.7% (95% CI, 0.4%-64.1%). The normal expected range of within-individual variability of the 6-lead ECG device was high (±50.2 milliseconds [coefficient of variation, 6.0%]) relative to the 12-lead ECG device (±22.0 milliseconds [coefficient of variation, 2.7%]). The mean (SD) increase in the 12-lead QTc measurement during treatment was 10.1 (25.8) milliseconds, with 0.8% of clinic visits (4 of 489) having a QTc interval of 500 milliseconds or more. Conclusions and Relevance This study suggests that simplified, handheld 6-lead ECG devices are effective triage tests that could reduce the need to perform 12-lead ECG monitoring in resource-constrained settings.
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Affiliation(s)
- John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Tamsin Economou
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Fahd Naufal
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | | | - Patrick P. J. Phillips
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Francesca Conradie
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Bhatnagar AK, Hemanthkumar AK, Muthu Vijayalakshmi M, Vohra V, Padmapriyadarsini C, Ramesh PM, Taneja G, Chavan VN, Jeyadeepa B, Bhui NK, Solanki R. Effect of Bedaquiline and Delamanid Pharmacokinetics on Sputum Culture Conversion and Adverse Events in Drug-Resistant Tuberculosis. Ther Drug Monit 2024; 46:363-369. [PMID: 38161267 PMCID: PMC11078291 DOI: 10.1097/ftd.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Pharmacokinetic studies of bedaquiline and delamanid in patients with pre-extensively drug-resistant tuberculosis (pre-XDR TB) will help in the optimization of these drugs for both culture conversion and adverse events. METHODS A prospective cohort of 165 adult patients (56% male with mean [SD] age 29 [9.7] years) with pre-XDR TB was treated with bedaquiline, delamanid, clofazimine, and linezolid for 24 weeks at 5 sites in India. Bedaquiline was administered at 400 mg daily for 2 weeks followed by 200 mg thrice weekly for 22 weeks, whereas delamanid was administered at 100 mg twice daily. In 23 consenting participants at 8 and 16 weeks of treatment, blood was collected at 0, 2, 4, 5, 6, 8, 12, and 24 hours postdosing for an intense pharmacokinetic study. Pharmacokinetic parameters were correlated with sputum culture conversion and adverse events. RESULTS The mean (SD) age and weight of patients were 30 (10) years and 54 kg, respectively. The median minimum concentration (C min ) and time-concentration curve (AUC) for bedaquiline, respectively, were 0.6 mcg/mL and 27 mcg/mL·h at week 8 and 0.8 mcg/mL and 36 mcg/mL·h at week 16, suggesting drug accumulation over time. The median C min and AUC of delamanid, respectively, were 0.17 mcg/mL and 5.1 mcg/mL·h at week 8 and 0.20 mcg/mL and 7.5 mcg/mL·h at week 16. Delay in sputum conversion was observed in patients with drug concentrations lower than the targeted concentration. At weeks 8 and 16, 13 adverse events were observed. Adverse events were resolved through symptomatic treatment. Body mass index was found to be significantly associated with drug-exposure parameters. CONCLUSIONS Bedaquiline and delamanid when co-administered exhibit plasma drug levels within the targeted concentrations, showing an exposure-response relationship.
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Affiliation(s)
- Anuj K. Bhatnagar
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, New Delhi
| | | | | | - Vikram Vohra
- National Institute for Tuberculosis and Respiratory Diseases, New Delhi
| | | | | | - Gaurav Taneja
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, New Delhi
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Schönfeld N, Barkane L, Davoliene I, Danilovits M, Miliauskas S, Ader F, Kon OM, Lange C, Duvignaud A, Heiss-Neumann M, Hittel N, Lazarević N, Knebel I, Martin A, Eschenbach B, van Heumen E, George V. Real-life use of delamanid: results from the European post-authorisation safety study. IJTLD OPEN 2024; 1:274-278. [PMID: 39021446 PMCID: PMC11249655 DOI: 10.5588/ijtldopen.24.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/23/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND A post-authorisation safety study (PASS) on delamanid (DLM) was conducted as part of a post-approval commitment to the European Medicines Agency. The aim of this study was to evaluate the use of DLM in a real-life setting, its safety, and treatment outcomes in patients with multidrug-resistant TB (MDR-TB). METHODS This was a prospective, multicentric, non-interventional study conducted in the European Union. MDR-TB Regimen selection and patient monitoring were conducted in accordance with existing medical practices. Data on the use of DLM, related adverse events, and treatment outcomes were collected for up to 30 months after the first DLM dose. Descriptive summary statistics were used for continuous and categorical variables. RESULTS Out of 86 patients, one had extrapulmonary TB. Two-thirds of the patients were treated with DLM for more than 24 weeks. The most frequent adverse drug reaction to DLM was QT interval prolongation. Resistance to DLM was detected in one patient during treatment. The treatment success rate was 77%. CONCLUSION No new safety concerns were revealed, including in patients treated with DLM for more than 24 weeks. QT interval prolongations were well managed and did not lead to any clinically significant cardiac effects. The treatment outcomes were in line with the WHO target for Europe.
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Affiliation(s)
- N Schönfeld
- Helios Klinikum Emil von Behring, Berlin, Germany
| | - L Barkane
- Riga East University Hospital, Riga, Latvia
| | - I Davoliene
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | | | - S Miliauskas
- Department of Pulmonology, Lithuania University of Health Sciences, Kaunas, Lithuania
| | - F Ader
- Hospices Civils de Lyon, Département des Maladies Infectieuses et Tropicales, Lyon, France
| | - O M Kon
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - C Lange
- Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Hamburg-Lübeck-Borstel Riems, Borstel, Germany
- Respiratory Medicine & International Health, University Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children´s Hospital, Global TB Program, Houston, TX, USA
| | - A Duvignaud
- Department of Infectious Diseases and Tropical Medicine, Centre Hospitalier Universitaire de Bordeaux-Groupe Hospitalier Pellegrin, Bordeaux, France
| | | | - N Hittel
- Otsuka Novel Products, Munich, Germany
| | | | - I Knebel
- Otsuka Novel Products, Munich, Germany
| | - A Martin
- Otsuka Novel Products, Munich, Germany
| | | | | | - V George
- Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ, USA
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Yu J, Ren W, Yuan J, Liu R, Ma L, Tang S, Pang Y. Identification of urine biomarkers predictive of prolonged QTc interval in multidrug-resistant tuberculosis patients treated with bedaquiline. Front Pharmacol 2024; 15:1362544. [PMID: 38873419 PMCID: PMC11169739 DOI: 10.3389/fphar.2024.1362544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 05/15/2024] [Indexed: 06/15/2024] Open
Abstract
The most frequent adverse event associated with bedaquiline (BDQ) is the QTc interval prolongation; however, there was no biomarkers that could be used to predict the occurrence of QTc prolongation in BDQ-treated patients. In this study, we employed the ultra-high performance liquid chromatography-MS/MS (UHPLC-MS/MS) to generate metabolic profiling for the discovery of potential predictive urine biomarkers of QTc prolongation in these patients. Untargeted metabolomic technique was used to concentrate the differential metabolic pathway, and targeted metabolomic technique was subsequently performed to identify predictive biomarkers for QTc prolongation. A total of 45 rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB) patients were enrolled in our study, including 15 RR/MDR-TB patients with QTc interval prolongation (QIP) and 30 RR/MDR-TB patients with QTc interval un-prolongations (QIU). Untargeted technique revealed that the lipid metabolism was the most differential metabolic pathway between two groups. Further targeted technique identified four differential metabolites, including betaine, LPE (18:2), LPE (20:3), and LPE (20:4). The combined analysis of metabolisms revealed that the combined use of LPE (20:3) and LPE (20:4) had the best performance for predicting the occurrence of QTc prolongation in TB patients, yielding a sensitivity of 87.4% and a specificity of 78.5%. In addition, with the progression of BDQ treatment, the LPEs exhibited persistent difference in the BDQ-treated TB patients experiencing QTc interval prolongation. In conclusion, our data demonstrate that the combined use of LPE (20:3) and LPE (20:4) yields promising performance for predicting the occurrence of QTc interval prolongation in BDQ-treated patients.
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Affiliation(s)
- Jiajia Yu
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Weicong Ren
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Jinfeng Yuan
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Rongmei Liu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Liping Ma
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Shenjie Tang
- Clinical Center on Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Yu Pang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
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Paliwal H, Nakpheng T, Kumar Paul P, Prem Ananth K, Srichana T. Development of a self-microemulsifying drug delivery system to deliver delamanid via a pressurized metered dose inhaler for treatment of multi-drug resistant pulmonary tuberculosis. Int J Pharm 2024; 655:124031. [PMID: 38521375 DOI: 10.1016/j.ijpharm.2024.124031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/06/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
Tuberculosis (TB) is a serious health issue that contributes to millions of deaths throughout the world and increases the threat of serious pulmonary infections in patients with respiratory illness. Delamanid is a novel drug approved in 2014 to deal with multi-drug resistant TB (MDR-TB). Despite its high efficiency in TB treatment, delamanid poses delivery challenges due to poor water solubility leading to inadequate absorption upon oral administration. This study involves the development of novel formulation-based pressurized metered dose inhalers (pMDIs) containing self-microemulsifying mixtures of delamanid for efficient delivery to the lungs. To identify the appropriate self-microemulsifying formulations, ternary diagrams were plotted using different combinations of surfactant to co-surfactant ratios (1:1, 2:1, and 3:1). The combinations used Cremophor RH40, Poly Ethylene Glycol 400 (PEG 400), and peppermint oil, and those that showed the maximum microemulsion region and rapid and stable emulsification were selected for further characterization. The diluted self-microemulsifying mixtures underwent evaluation of dose uniformity, droplet size, zeta potential, and transmission electron microscopy. The selected formulations exhibited uniform delivery of the dose throughout the canister life, along with droplet sizes and zeta potentials that ranged from 24.74 to 88.99 nm and - 19.27 to - 10.00 mV, respectively. The aerosol performance of each self-microemulsifying drug delivery system (SMEDDS)-pMDI was assessed using the Next Generation Impactor, which indicated their capability to deliver the drug to the deeper areas of the lungs. In vitro cytotoxicity testing on A549 and NCI-H358 cells revealed no significant signs of toxicity up to a concentration of 1.56 µg/mL. The antimycobacterial activity of the formulations was evaluated against Mycobacterium bovis using flow cytometry analysis, which showed complete inhibition by day 5 with a minimum bactericidal concentration of 0.313 µg/mL. Moreover, the cellular uptake studies showed efficient delivery of the formulations inside macrophage cells, which indicated the potential for intracellular antimycobacterial activity. These findings demonstrated the potential of the Delamanid-SMEDDS-pMDI for efficient pulmonary delivery of delamanid to improve its effectiveness in the treatment of multi-drug resistant pulmonary TB.
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Affiliation(s)
- Himanshu Paliwal
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand; Department of Pharmaceutics, Sanjivani College of Pharmaceutical Education and Research, Kopargaon 423603, Maharashtra, India
| | - Titpawan Nakpheng
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pijush Kumar Paul
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand; Department of Pharmacy, Gono Bishwabidyalay (University), Dhaka 1344, Bangladesh
| | - K Prem Ananth
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Teerapol Srichana
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
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Mikiashvili L, Kempker RR, Chakhaia TS, Bablishvili N, Avaliani Z, Lomtadze N, Schechter MC, Kipiani M. Impact of Prior Tuberculosis Treatment With New/Companion Drugs on Clinical Outcomes in Patients Receiving Concomitant Bedaquiline and Delamanid for Multidrug- and Rifampicin-Resistant Tuberculosis. Clin Infect Dis 2024; 78:1043-1052. [PMID: 37962987 PMCID: PMC11006115 DOI: 10.1093/cid/ciad694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND There are scarce data on the clinical outcomes of persons retreated with new/companion anti-tuberculosis (TB) drugs for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). We sought to evaluate the efficacy and safety of bedaquiline and delamanid containing regimens among patients with and without prior exposure to the new/companion drugs (bedaquiline, delamanid, linezolid, clofazimine, and fluoroquinolones). METHODS We conducted a retrospective cohort study among patients with pulmonary MDR/RR-TB in Georgia who received bedaquiline and delamanid combination as a part of a salvage regimen from November 2017 to December 2020 in a programmatic setting. RESULTS Among 106 persons with a median age of 39.5 years, 44 (41.5%) were previously treated with new/companion TB drugs. Patients with prior exposure to new/companion drugs had higher rates of baseline resistance compared to those without exposure to new/companion TB drugs (bedaquiline 15.2% vs 1.8%, linezolid 22.2% vs 16.7%). Sputum culture conversion rates among patients exposed and not exposed to new/companion drugs were 65.9% vs 98.0%, respectively (P < .001). Among patients with and without prior new/companion TB drug use, favorable outcome rates were 41.0% and 82.3%, respectively (P < .001). Treatment adherence in 32 (30.2%) patients was ≤80%. Five of 21 patients (23.8%) who had a baseline and repeat susceptibility test had acquired bedaquiline resistance. QTC/F prolongation (>500 ms) was rare (2.8%). CONCLUSIONS Prior exposure to new/companion TB drugs was associated with poor clinical outcomes and acquired drug resistance. Tailoring the TB regimen to each patient's drug susceptibility test results and burden of disease and enhancing adherence support may improve outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - T S Chakhaia
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - N Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
| | - M C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
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Gao J, Gao M, Du J, Pang Y, Mao G, Lounis N, Bakare N, Jiang Y, Zhan Y, Liu Y, Li L. A pragmatic randomized controlled trial to evaluate the efficacy and safety of an oral short-course regimen including bedaquiline for the treatment of patients with multidrug-resistant tuberculosis in China: study protocol for PROSPECT. Trials 2024; 25:227. [PMID: 38561815 PMCID: PMC10986125 DOI: 10.1186/s13063-024-07946-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The lack of safe, effective, and simple short-course regimens (SCRs) for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) treatment has significantly impeded TB control efforts in China. METHODS This phase 4, randomized, open-label, controlled, non-inferiority trial aims to assess the efficacy and safety of a 9-month all-oral SCR containing bedaquiline (BDQ) versus an all-oral SCR without BDQ for adult MDR-TB patients (18-65 years) in China. The trial design mainly mirrors that of the "Evaluation of a Standardized Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB" (STREAM) stage 2 study, while also incorporating programmatic data from South Africa and the 2019 consensus recommendations of Chinese MDR/RR-TB treatment experts. Experimental arm participants will receive a modified STREAM regimen C that replaces three group C drugs, ethambutol (EMB), pyrazinamide (PZA), and prothionamide (PTO), with two group B drugs, linezolid (LZD) and cycloserine (CS), while omitting high-dose isoniazid (INH) for confirmed INH-resistant cases. BDQ duration will be extended from 6 to 9 months for participants with Mycobacterium tuberculosis-positive sputum cultures at week 16. The control arm will receive a modified STREAM regimen B without high-dose INH and injectable kanamycin (KM) that incorporates experimental arm LZD and CS dosages, treatment durations, and administration methods. LZD (600 mg) will be given daily for ≥ 24 weeks as guided by observed benefits and harm. The primary outcome measures the proportion of participants with favorable treatment outcomes at treatment completion (week 40), while the same measurement taken at 48 weeks post-treatment completion is the secondary outcome. Assuming an α = 0.025 significance level (one-sided test), 80% power, 15% non-inferiority margin, and 10% lost to follow-up rate, each arm requires 106 participants (212 total) to demonstrate non-inferiority. DISCUSSION PROSPECT aims to assess the safety and efficacy of a BDQ-containing SCR MDR-TB treatment at seventeen sites across China, while also providing high-quality data to guide SCRs administration under the direction of the China National Tuberculosis Program for MDR-TB. Additionally, PROSPECT will explore the potential benefits of extending the administration of the 9-month BDQ-containing SCR for participants without sputum conversion by week 16. TRIAL REGISTRATION ClinicalTrials.gov NCT05306223. Prospectively registered on 16 March 2022 at https://clinicaltrials.gov/ct2/show/NCT05306223?term=NCT05306223&draw=1&rank=1 {2}.
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Affiliation(s)
- Jingtao Gao
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Mengqiu Gao
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, 101149, People's Republic of China
| | - Jian Du
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Yu Pang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, 101149, People's Republic of China
| | - Gary Mao
- Janssen Global Public Health, Janssen Research & Development, Titusville, NJ, USA
| | | | - Nyasha Bakare
- Janssen Global Public Health, Janssen Research & Development, Titusville, NJ, USA
| | - Yanxin Jiang
- Janssen China Research & Development, Shanghai, People's Republic of China
| | - Ying Zhan
- Innovation Alliance On Tuberculosis Diagnosis and Treatment (Beijing) [IATB], Beijing, 101100, People's Republic of China
| | - Yuhong Liu
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China.
| | - Liang Li
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China.
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Dawson R, Diacon AH, Takuva S, Liu Y, Zheng B, Karwe V, Hafkin J. Quabodepistat in combination with delamanid and bedaquiline in participants with drug-susceptible pulmonary tuberculosis: protocol for a multicenter, phase 2b/c, open-label, randomized, dose-finding trial to evaluate safety and efficacy. Trials 2024; 25:70. [PMID: 38243296 PMCID: PMC10799444 DOI: 10.1186/s13063-024-07912-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Delamanid and bedaquiline are two of the most recently developed antituberculosis (TB) drugs that have been extensively studied in patients with multidrug-resistant TB. There is currently a need for more potent, less-toxic drugs with novel mechanisms of action that can be used in combination with these newer agents to shorten the duration of treatment as well as prevent the development of drug resistance. Quabodepistat (QBS) is a newly discovered inhibitor of decaprenylphosphoryl-β-D-ribose-2'-oxidase, an essential enzyme for Mycobacterium tuberculosis to synthesize key components of its cell wall. The objective of this study is to evaluate the safety, efficacy, and appropriate dosing of a 4-month regimen of QBS in combination with delamanid and bedaquiline in participants with drug-susceptible pulmonary TB in comparison with the 6-month standard treatment (i.e., rifampicin, isoniazid, ethambutol, and pyrazinamide). METHODS This phase 2b/c, open-label, randomized, parallel group, dose-finding trial will enroll approximately 120 participants (including no more than 15% with human immunodeficiency virus [HIV] coinfection) aged ≥ 18 to ≤ 65 years at screening with newly diagnosed pulmonary drug-sensitive TB from ~8 sites in South Africa. Following a screening period of up to 14 days, eligible participants will be randomized in a ratio of 1:2:2:1 to one of four arms. Randomization will be stratified by HIV status and the presence of bilateral cavitation on a screening chest x-ray. After the end of the treatment period, participants will be followed until 12 months post randomization. The primary efficacy endpoint is the proportion of participants achieving sputum culture conversion in Mycobacteria Growth Indicator Tube by the end of the treatment period. The safety endpoints consist of adverse events, clinical laboratory tests, vital signs, physical examination findings, and electrocardiographic changes. DISCUSSION QBS's potent bactericidal activity and distinct mechanism of action (compared with other TB drugs currently available for human use) may make it an ideal candidate for inclusion in a novel treatment regimen to improve efficacy and potentially prevent resistance to concomitant TB drugs. This trial will assess the effectiveness, safety, and dosing of a new, shorter, QBS-based, combination anti-TB treatment regimen. TRIAL STATUS ClinicalTrials.gov NCT05221502. Registered on February 3, 2022.
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Affiliation(s)
- Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Andreas H Diacon
- Department of Medicine, Stellenbosch University, Cape Town, South Africa
- TASK Applied Science, Cape Town, South Africa
| | - Simbarashe Takuva
- Otsuka Novel Products GmbH, Munich, Germany
- Faculty of Health Sciences, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Yongge Liu
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | - Bo Zheng
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | - Vatsala Karwe
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | - Jeffrey Hafkin
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA.
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10
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Ahmed SH, Haider H, Moeed A, Mahmood A, Shivani N, Shuja SH, Hayat J, Jamil B, Fatima R. Efficacy and safety of bedaquiline and delamanid in the treatment of drug-resistant tuberculosis in adults: A systematic review and meta-analysis. Indian J Tuberc 2024; 71:79-88. [PMID: 38296395 DOI: 10.1016/j.ijtb.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 02/15/2024]
Abstract
Multi and extensively drug-resistant tuberculosis is a grave cause of global public health concern due to its high mortality and limited treatment options. We conducted this systemic review and meta-analysis to evaluate the efficacy and safety of bedaquiline and delamanid, which have been added to the WHO-recommended regimen for treating drug-resistant tuberculosis. Electronic databases were searched from their inception until December 1st, 2021, for eligible studies assessing the efficacy and safety of bedaquiline and delamanid for treating drug-resistant tuberculosis. Binary outcomes were pooled using a DerSimonian-Laird random-effects model and arcsine transformation and reported on a log scale with a 95% confidence interval (CIs). Twenty-one studies were shortlisted in which bedaquiline, delamanid, and a combination of both were administered in 2477, 937, and 169 patients. Pooled culture conversion at 6 months was 0.801 (p < 0.001), 0.849 (p = 0.059) for bedaquiline and delamanid, respectively, and 0.823 (p = 0.017), concomitantly. In the bedaquiline cohort, the pooled proportion of all-cause mortality at 6 months was reported as 0.074 (p < 0.001), 0.031 (p = 0.372) in the delamanid cohort, and 0.172 in the combined cohort. The incidence of adverse events in the bedaquiline cohort ranged from 11.1% to 95.2%, from 13.2% to 86.2% in the delamanid cohort, and 92.5% in a study in the combined cohort. The incidence of QTC prolongation reported in each cohort is as follows: bedaquiline 0.163 (p < 0.001), delamanid 0.344 (p = 0.272) and combined 0.340 (p < 0.001). Our review establishes the efficacy of delamanid, bedaquiline, and their combined use in treating drug-resistant tuberculosis with reasonable rates of culture conversion, low mortality rates, and safety of co-administration, as seen with their effect on the QTc interval.
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Affiliation(s)
- Syeda Hoorulain Ahmed
- Department of Internal Medicine, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, 74200, Pakistan.
| | - Hoorain Haider
- Department of Internal Medicine, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, 74200, Pakistan
| | - Abdul Moeed
- Department of Internal Medicine, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, 74200, Pakistan
| | - Aysal Mahmood
- Department of Internal Medicine, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, 74200, Pakistan
| | - Nasir Shivani
- Department of Medicine, Bedford Hospital, Bedford, Bedfordshire, United Kingdom
| | - Syed Hasan Shuja
- Department of Internal Medicine, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, 74200, Pakistan
| | - Javeria Hayat
- Department of Internal Medicine, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, 74200, Pakistan
| | - Bushra Jamil
- Department of Medicine, Aga Khan University, National Stadium Road, Karachi, 74800, Pakistan
| | - Razia Fatima
- Common Management Unit (TB, HIV/AIDS & Malaria), Islamabad, Pakistan
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11
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Ratto A, Honek JF. Oxocarbon Acids and their Derivatives in Biological and Medicinal Chemistry. Curr Med Chem 2024; 31:1172-1213. [PMID: 36915986 DOI: 10.2174/0929867330666230313141452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 03/15/2023]
Abstract
The biological and medicinal chemistry of the oxocarbon acids 2,3- dihydroxycycloprop-2-en-1-one (deltic acid), 3,4-dihydroxycyclobut-3-ene-1,2-dione (squaric acid), 4,5-dihydroxy-4-cyclopentene-1,2,3-trione (croconic acid), 5,6-dihydroxycyclohex- 5-ene-1,2,3,4-tetrone (rhodizonic acid) and their derivatives is reviewed and their key chemical properties and reactions are discussed. Applications of these compounds as potential bioisosteres in biological and medicinal chemistry are examined. Reviewed areas include cell imaging, bioconjugation reactions, antiviral, antibacterial, anticancer, enzyme inhibition, and receptor pharmacology.
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Affiliation(s)
- Amanda Ratto
- Department of Chemistry, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - John F Honek
- Department of Chemistry, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
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12
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Jin Y, Benkeser D, Kipiani M, Maranchick NF, Mikiashvili L, Barbakadze K, Avaliani Z, Alghamdi WA, Alshaer MH, Peloquin CA, Blumberg HM, Kempker RR. The effect of anti-tuberculosis drug pharmacokinetics on QTc prolongation. Int J Antimicrob Agents 2023; 62:106939. [PMID: 37517627 PMCID: PMC10538394 DOI: 10.1016/j.ijantimicag.2023.106939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/19/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Implementation of newer anti-tuberculosis (TB) drugs may prolong the QT interval, increasing the risk of arrythmias and sudden cardiac death. The potential for cardiac adverse events has prompted recommendations for frequent cardiac monitoring during treatment. However, unknowns remain, including the association between drug concentrations and QT interval. METHODS An observational prospective cohort study design was used. Patients undergoing treatment for drug-resistant TB in Georgia were assessed. Serial blood samples were collected at 4-6 weeks for pharmacokinetics. Electrocardiograms were recommended to be performed monthly. A generalized estimating equation spline model was used to investigate (1) the effect difference between bedaquiline and delamanid, (2) the cumulative effect of number of anti-TB drugs, and (3) the relationship between serum drug concentrations on QTc interval. RESULTS Among 94 patients receiving either bedaquiline (n = 64) or delamanid (n = 30)-based treatment, most were male (82%), and the mean age was 39 years. The mean maximum QTc increase during the first six months was 37.5 ms (IQR: 17.8-56.8). Bedaquiline- and delamanid-based regimens displayed similar increased mean QTc change from baseline during drug administration (P = 0.12). Increasing number of anti-TB drugs was associated with an increased QTc (P = 0.01), but participants trended back towards baseline after drug discontinuation (P = 0.25). A significant association between AUC, Cmin, Cmax, and increased QTc interval was found for bedaquiline (months 1-6) and levofloxacin (months 1-12). CONCLUSION Bedaquiline- and delamanid-based regimens and increasing number of QT prolonging agents led to modest increases in the QTc interval with minimal clinical effect.
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Affiliation(s)
- Yutong Jin
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.
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13
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Sachan RK, Mistry V, Dholaria M, Rana A, Devgon I, Ali I, Iqbal J, Eldin SM, Mohammad Said Al-Tawaha AR, Bawazeer S, Dutta J, Karnwal A. Overcoming Mycobacterium tuberculosis Drug Resistance: Novel Medications and Repositioning Strategies. ACS OMEGA 2023; 8:32244-32257. [PMID: 37720746 PMCID: PMC10500578 DOI: 10.1021/acsomega.3c02563] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023]
Abstract
Mycobacterium tuberculosis, the bacterium responsible for tuberculosis, is a global health concern, affecting millions worldwide. This bacterium has earned a reputation as a formidable adversary due to its multidrug-resistant nature, allowing it to withstand many antibiotics. The development of this drug resistance in Mycobacterium tuberculosis is attributed to innate and acquired mechanisms. In the past, rifampin was considered a potent medication for treating tuberculosis infections. However, the rapid development of resistance to this drug by the bacterium underscores the pressing need for new therapeutic agents. Fortunately, several other medications previously overlooked for tuberculosis treatment are already available in the market. Moreover, several innovative drugs are under clinical investigation, offering hope for more effective treatments. To enhance the effectiveness of these drugs, it is recommended that researchers concentrate on identifying unique target sites within the bacterium during the drug development process. This strategy could potentially circumvent the issues presented by Mycobacterium drug resistance. This review primarily focuses on the characteristics of novel drug resistance mechanisms in Mycobacterium tuberculosis. It also discusses potential medications being repositioned or sourced from novel origins. The ultimate objective of this review is to discover efficacious treatments for tuberculosis that can successfully tackle the hurdles posed by Mycobacterium drug resistance.
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Affiliation(s)
| | - Vyoma Mistry
- C.
G. Bhakta Institute of Biotechnology, Uka
Tarsadia University, Bardoli 394350, Surat, India
| | - Mayuri Dholaria
- Naran
Lala College of Professional and Applied Sciences, Navsari 396450, Gujarat, India
| | - Abhishek Rana
- Jindal
Global Law School, OP Jindal Global University, Sonepat 131001, Haryana, India
| | - Inderpal Devgon
- Lovely
Professional University, Phagwara 144411, Punjab, India
| | - Iftikhar Ali
- Center
for Plant Science and Biodiversity, University
of Swat, Charbagh 19120, Pakistan
- Department
of Genetics and Development, Columbia University
Irving Medical Center, New York, New York 10032, United States
| | - Javed Iqbal
- Department
of Botany, Bacha Khan University, Charsadda, 24420 Khyber Pakhtunkhwa, Pakistan
| | - Sayed M. Eldin
- Center
of Research, Faculty of Engineering, Future
University in Egypt, New Cairo 11835, Egypt
| | | | - Sami Bawazeer
- Faculty
of Pharmacy, Department of Pharmacognosy, Umm Al-Qura University, Makkah 4041-4152, Kingdom of Saudi Arabia
| | - Joydeep Dutta
- Lovely
Professional University, Phagwara 144411, Punjab, India
| | - Arun Karnwal
- Lovely
Professional University, Phagwara 144411, Punjab, India
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14
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Li R, Ma JB, Yang H, Yang H, Yang XJ, Wu YQ, Ren F. Effects of Bedaquiline Combined with Fluoroquinolone and/or Clofazimine on QT Interval in Patients with Multidrug-Resistant Tuberculosis: a Retrospective Study. Microbiol Spectr 2023; 11:e0104823. [PMID: 37310268 PMCID: PMC10434111 DOI: 10.1128/spectrum.01048-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/17/2023] [Indexed: 06/14/2023] Open
Abstract
With the application of bedaquiline (Bdq), the success rate of multidrug-resistant tuberculosis (MDR-TB) treatment has been significantly improved; however, the cardiac safety of the patients during treatment cannot be ignored. Hence, this study compared the effects of bedaquiline alone and bedaquiline combined with fluoroquinolones (FQs) and/or clofazimine (CFZ) on the QT interval. This single-center retrospective cohort study analyzed the clinical data of MDR-TB patients treated with bedaquiline for 24 weeks from January 2020 to May 2021 in Xi'an Chest Hospital and compared the changes in QTcF between the two groups. Eighty-five patients were included in the study and grouped by types of anti-TB drugs affecting the QT interval they used. Group A included bedaquiline (n = 33), and group B included bedaquiline in combination with fluoroquinolones and/or clofazimine (n = 52). Out of patients with available corrected QT interval by Fridericia's formula (QTcF) data, 2.4% (2/85) experienced a postbaseline QTcF of ≥500 ms, and 24.7% (21/85) had at least one change of QTcF of ≥60 ms from baseline. In group A, 9.1% (3/33) had at least one ΔQTcF of >60 ms, as did 34.6% (18/52) of group B. Multivariate Cox regression analysis showed that the adjusted risk of QT prolongation was 4.82 times higher in group B (95% confidence interval [CI], 1.406 to 16.488). Bedaquiline combined with other anti-TB drugs affecting QT interval significantly increased the incidence of grade 3 or 4 QT prolongation; however, no serious ventricular arrhythmia and permanent drug withdrawal occurred. The use of bedaquiline combined with fluoroquinolone and/or clofazimine is an independent risk factor affecting QT interval. IMPORTANCE Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis. The emergence of MDR-TB is caused by an organism that is resistant to at least isoniazid and rifampin and is currently considered the major challenge for the global control of TB. Bedaquiline is the first new TB drug in 50 years with a unique mechanism of action, strong anti-M. tuberculosis activity. Yet unexplained excess deaths in the bedaquiline arms have been found in some phase II clinical trials; thus, the FDA has issued a "boxed warning." However, the cardiac safety of the patients during treatment cannot be ignored. Accordingly, further investigations are needed to establish whether bedaquiline combined with clofazimine, fluoroquinolones, or anti-TB drugs affecting the QT interval in a long-course or short-course treatment increases the risk of QT prolongation.
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Affiliation(s)
- Rong Li
- Department of Drug-resistance tuberculosis, Xi’an Chest Hospital, Xi’an, China
| | - Jin-Bao Ma
- Department of Drug-resistance tuberculosis, Xi’an Chest Hospital, Xi’an, China
| | - Hong Yang
- Department of Drug-resistance tuberculosis, Xi’an Chest Hospital, Xi’an, China
| | - Han Yang
- Medical Transformation Center of Xi’an Chest Hospital, Xi’an, China
| | - Xin-Jun Yang
- Department of Drug-resistance tuberculosis, Xi’an Chest Hospital, Xi’an, China
| | - Yan-Qin Wu
- Department of Drug-resistance tuberculosis, Xi’an Chest Hospital, Xi’an, China
| | - Fei Ren
- Department of Drug-resistance tuberculosis, Xi’an Chest Hospital, Xi’an, China
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15
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Cattaneo D, Torre A, Schiuma M, Civati A, Lazzarin S, Rizzardini G, Gori A, Antinori S, Gervasoni C. Management of Polypharmacy and Potential Drug-Drug Interactions in Patients with Mycobacterial Infection: A 1-Year Experience of a Multidisciplinary Outpatient Clinic. Antibiotics (Basel) 2023; 12:1171. [PMID: 37508267 PMCID: PMC10375959 DOI: 10.3390/antibiotics12071171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
In 2022, we opened an outpatient clinic for the management of polypharmacy and potential drug-drug interactions (pDDIs) in patients with mycobacterial infection (called GAP-MyTB). All patients who underwent a GAP-MyTB visit from March 2022 to March 2023 were included in this retrospective analysis. Fifty-two patients were included in the GAP-MyTB database. They were given 10.4 ± 3.7 drugs (2.8 ± 1.0 and 7.8 ± 3.9 were, respectively, antimycobacterial agents and co-medications). Overall, 262 pDDIs were identified and classified as red-flag (2%), orange-flag (72%), or yellow-flag (26%) types. The most frequent actions suggested after the GAP-MyTB assessment were to perform ECG (52%), therapeutic drug monitoring (TDM, 40%), and electrolyte monitoring (33%) among the diagnostic interventions and to reduce/stop proton pump inhibitors (37%), reduce/change statins (14%), and reduce anticholinergic burden (8%) among the pharmacologic interventions. The TDM of rifampicin revealed suboptimal exposure in 39% of patients that resulted in a TDM-guided dose increment (from 645 ± 101 to 793 ± 189 mg/day, p < 0.001). The high prevalence of polypharmacy and risk of pDDIs in patients with mycobacterial infection highlights the need for ongoing education on prescribing principles and the optimal management of individual patients. A multidisciplinary approach involving physicians and clinical pharmacologists could help achieve this goal.
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Affiliation(s)
- Dario Cattaneo
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Alessandro Torre
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Marco Schiuma
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Aurora Civati
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Samuel Lazzarin
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Giuliano Rizzardini
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Andrea Gori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Spinello Antinori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Cristina Gervasoni
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
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16
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Dierig A, Hoelscher M, Schultz S, Hoffmann L, Jarchow-MacDonald A, Svensson EM, Te Brake L, Aarnoutse R, Boeree M, McHugh TD, Wildner LM, Gong X, Phillips P, Minja LT, Ntinginya N, Mpagama S, Liyoyo A, Wallis RS, Sebe M, Mhimbira FA, Mbeya B, Rassool M, Geiter L, Cho YL, Heinrich N. A phase IIb, open-label, randomized controlled dose ranging multi-centre trial to evaluate the safety, tolerability, pharmacokinetics and exposure-response relationship of different doses of delpazolid in combination with bedaquiline delamanid moxifloxacin in adult subjects with newly diagnosed, uncomplicated, smear-positive, drug-sensitive pulmonary tuberculosis. Trials 2023; 24:382. [PMID: 37280643 DOI: 10.1186/s13063-023-07354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Linezolid is an effective, but toxic anti-tuberculosis drug that is currently recommended for the treatment of drug-resistant tuberculosis. Improved oxazolidinones should have a better safety profile, while preserving efficacy. Delpazolid is a novel oxazolidinone developed by LegoChem Biosciences Inc. that has been evaluated up to phase 2a clinical trials. Since oxazolidinone toxicity can occur late in treatment, LegoChem Biosciences Inc. and the PanACEA Consortium designed DECODE to be an innovative dose-ranging study with long-term follow-up for determining the exposure-response and exposure-toxicity relationship of delpazolid to support dose selection for later studies. Delpazolid is administered in combination with bedaquiline, delamanid and moxifloxacin. METHODS Seventy-five participants with drug-sensitive, pulmonary tuberculosis will receive bedaquiline, delamanid and moxifloxacin, and will be randomized to delpazolid dosages of 0 mg, 400 mg, 800 mg, 1200 mg once daily, or 800 mg twice daily, for 16 weeks. The primary efficacy endpoint will be the rate of decline of bacterial load on treatment, measured by MGIT liquid culture time to detection from weekly sputum cultures. The primary safety endpoint will be the proportion of oxazolidinone class toxicities; neuropathy, myelosuppression, or tyramine pressor response. Participants who convert to negative liquid media culture by week 8 will stop treatment after the end of their 16-week course and will be observed for relapse until week 52. Participants who do not convert to negative culture will receive continuation phase treatment with rifampicin and isoniazid to complete a six-month treatment course. DISCUSSION DECODE is an innovative dose-finding trial, designed to support exposure-response modelling for safe and effective dose selection. The trial design allows assessment of occurrence of late toxicities as observed with linezolid, which is necessary in clinical evaluation of novel oxazolidinones. The primary efficacy endpoint is the change in bacterial load, an endpoint conventionally used in shorter dose-finding trials. Long-term follow-up after shortened treatment is possible through a safety rule excluding slow-and non-responders from potentially poorly performing dosages. TRIAL REGISTRATION DECODE was registered in ClinicalTrials.gov before recruitment start on 22 October 2021 (NCT04550832).
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Affiliation(s)
- A Dierig
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich partner site, Munich, Germany
| | - M Hoelscher
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich partner site, Munich, Germany
| | - S Schultz
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich partner site, Munich, Germany
| | - L Hoffmann
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich partner site, Munich, Germany
| | - A Jarchow-MacDonald
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich partner site, Munich, Germany
- Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - E M Svensson
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - L Te Brake
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R Aarnoutse
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M Boeree
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - T D McHugh
- Division of Infection & Immunity, UCL Centre for Clinical Microbiology, University College of London, London, UK
| | - L M Wildner
- Division of Infection & Immunity, UCL Centre for Clinical Microbiology, University College of London, London, UK
| | - X Gong
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Ppj Phillips
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - L T Minja
- National Institute for Medical Research, Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - N Ntinginya
- National Institute for Medical Research, Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - S Mpagama
- Kilimanjaro Clinical Research Institute, Kilimanjaro, Tanzania
| | - A Liyoyo
- Kilimanjaro Clinical Research Institute, Kilimanjaro, Tanzania
| | - R S Wallis
- The Aurum Institute, Tembisa, South Africa
| | - M Sebe
- The Aurum Institute, Tembisa, South Africa
| | - F A Mhimbira
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - B Mbeya
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - M Rassool
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - L Geiter
- LegoChem Biosciences, Daejeon, South Korea
| | - Y L Cho
- LegoChem Biosciences, Daejeon, South Korea
| | - N Heinrich
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany.
- German Center for Infection Research (DZIF), Munich partner site, Munich, Germany.
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Trevisi L, Hernán MA, Mitnick CD, Khan U, Seung KJ, Rich ML, Bastard M, Huerga H, Melikyan N, Atwood SA, Avaliani Z, Llanos F, Manzur-ul-Alam M, Zarli K, Binegdie AB, Adnan S, Melikyan A, Gelin A, Isani AK, Vetushko D, Daugarina Z, Nkundanyirazo P, Putri FA, Vilbrun C, Khan M, Hewison C, Khan PY, Franke MF. Effectiveness of Bedaquiline Use beyond Six Months in Patients with Multidrug-Resistant Tuberculosis. Am J Respir Crit Care Med 2023; 207:1525-1532. [PMID: 36802336 PMCID: PMC10263131 DOI: 10.1164/rccm.202211-2125oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Rationale: Current recommendations for the treatment of rifampicin- and multidrug-resistant tuberculosis include bedaquiline (BDQ) used for 6 months or longer. Evidence is needed to inform the optimal duration of BDQ. Objectives: We emulated a target trial to estimate the effect of three BDQ duration treatment strategies (6, 7-11, and ⩾12 mo) on the probability of successful treatment among patients receiving a longer individualized regimen for multidrug-resistant tuberculosis. Methods: To estimate the probability of successful treatment, we implemented a three-step approach comprising cloning, censoring, and inverse probability weighting. Measurements and Main Results: The 1,468 eligible individuals received a median of 4 (interquartile range, 4-5) likely effective drugs. In 87.1% and 77.7% of participants, this included linezolid and clofazimine, respectively. The adjusted probability of successful treatment was 0.85 (95% confidence interval [CI], 0.81-0.88) for 6 months of BDQ, 0.77 (95% CI, 0.73-0.81) for 7-11 months, and 0.86 (95% CI, 0.83-0.88) for ⩾12 months. Compared with 6 months of BDQ, the ratio of treatment success was 0.91 (95% CI, 0.85-0.96) for 7-11 months and 1.01 (95% CI, 0.96-1.06) for ⩾12 months. Naive analyses that did not account for bias revealed a higher probability of successful treatment with ⩾12 months (ratio, 1.09 [95% CI, 1.05-1.14]). Conclusions: BDQ use beyond 6 months did not increase the probability of successful treatment among patients receiving longer regimens that commonly included new and repurposed drugs. When not properly accounted for, immortal person-time bias can influence estimates of the effects of treatment duration. Future analyses should explore the effect of treatment duration of BDQ and other drugs in subgroups with advanced disease and/or receiving less potent regimens.
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Affiliation(s)
- Letizia Trevisi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Miguel A. Hernán
- CAUSALab, Departments of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | - Uzma Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Kwonjune J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | - Michael L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | | | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Nara Melikyan
- Field Epidemiology Department, Epicentre, Paris, France
| | - Sidney A. Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Felix Llanos
- Unidad de Tuberculosis, Hospital Nacional Dos de Mayo, Lima, Peru
- Instituto de Investigaciones en Ciencias Biomedicas, Universidad Ricardo Palma, Lima, Peru
| | | | - Khin Zarli
- Médecins sans Frontières, Yangon, Myanmar
| | - Amsalu Bekele Binegdie
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sana Adnan
- Indus Hospital and Health Network, Karachi, Pakistan
| | | | | | - Afshan K. Isani
- National Core Research Group, Stop TB Partnership, Islamabad, Pakistan
| | - Dmitry Vetushko
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis, Minsk, Belarus
| | | | | | | | | | - Munira Khan
- Interactive Research and Development, Durban, South Africa
| | | | - Palwasha Y. Khan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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Graciaa DS, Schechter MC, Fetalvero KB, Cranmer LM, Kempker RR, Castro KG. Updated considerations in the diagnosis and management of tuberculosis infection and disease: integrating the latest evidence-based strategies. Expert Rev Anti Infect Ther 2023; 21:595-616. [PMID: 37128947 PMCID: PMC10227769 DOI: 10.1080/14787210.2023.2207820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/24/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious cause of global morbidity and mortality, affecting nearly a quarter of the human population and accounting for over 10 million deaths each year. Over the past several decades, TB incidence and mortality have gradually declined, but 2021 marked a threatening reversal of this trend highlighting the importance of accurate diagnosis and effective treatment of all forms of TB. AREAS COVERED This review summarizes advances in TB diagnostics, addresses the treatment of people with TB infection and TB disease including recent evidence for treatment regimens for drug-susceptible and drug-resistant TB, and draws attention to special considerations in children and during pregnancy. EXPERT OPINION Improvements in diagnosis and management of TB have expanded the available options for TB control. Molecular testing has enhanced the detection of TB disease, but better diagnostics are still needed, particularly for certain populations such as children. Novel treatment regimens have shortened treatment and improved outcomes for people with TB. However, important questions remain regarding the optimal management of TB. Work must continue to ensure the potential of the latest developments is realized for all people affected by TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos Coutinho Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Krystle B. Fetalvero
- Angelo King Medical Research Center-De La Salle Medical and Health Science Institute, Cavite, Philippines
- Department of Family and Community Medicine, Calamba Medical Center, Laguna, Philippines
| | - Lisa Marie Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kenneth G. Castro
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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19
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Mazanhanga MT, Joubert A, Castel SA, van der Merwe M, Maartens G, Dooley KE, Upton CM, Wiesner L. Liquid chromatography-tandem mass spectrometry analysis of delamanid and its metabolite in human cerebrospinal fluid using protein precipitation and on-line solid-phase extraction. J Pharm Biomed Anal 2023; 227:115281. [PMID: 36739721 PMCID: PMC10023415 DOI: 10.1016/j.jpba.2023.115281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
The penetration of the antituberculosis drug delamanid into the central nervous system is not established. The distribution of delamanid and its major metabolite, DM-6705, into the cerebrospinal fluid requires investigation. A liquid chromatography-tandem mass spectrometry method for the quantification of delamanid and DM-6705 in human cerebrospinal fluid was developed and validated. The calibration range for both analytes was 0.300 - 30.0 ng/mL. The deuterium-labelled analogue of delamanid (delamanid-d4) and OPC-14714 were used as internal standards for delamanid and DM-6705, respectively. Samples were processed by protein precipitation followed by on-line solid-phase extraction and high-performance liquid chromatography on an Agilent 1260 HPLC system. A Phenomenex Gemini-NX C18 (5.0 µm, 50 mm × 2.0 mm) analytical column was used for on-line solid-phase extraction, and a Waters Xterra MS C18 (5.0 µm, 100 mm × 2.1 mm) analytical column for chromatographic separation using gradient elution, at a flow rate of 300 µL/min. The total run time was 7.5 min. Analytes were detected by multiple reaction monitoring on an AB Sciex 5500 triple quadrupole mass spectrometer at unit mass resolution, with electrospray ionization in the positive mode. Accuracy and precision were assessed over three independent validation batches. Extraction recoveries were more than 98% and were consistent across the analytical range. Both analytes in CSF exhibited non-specific adsorption to polypropylene tubes. The method was used to analyse cerebrospinal fluid samples from patients with pulmonary tuberculosis in an exploratory pharmacokinetic study.
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Affiliation(s)
- Marian T Mazanhanga
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra A Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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20
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Davies GR, Aston S. Update on drug treatments for multidrug resistant tuberculosis. Curr Opin Infect Dis 2023; 36:132-139. [PMID: 36718913 DOI: 10.1097/qco.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF THE REVIEW To describe important recent developments in the treatment of multidrug resistant tuberculosis (MDR-TB). RECENT FINDINGS In the last decade, novel and repurposed antituberculosis drugs have transformed MDR-TB treatment with improved rates of treatment success, better tolerability and safety and reduced duration. As recently as 2016, standard care relied on up to seven drugs for 24 months with treatment success no better than 70%. Seven drug shorter so-called "Bangladesh" style regimens subsequently achieved similar or better results at a duration of 9-12 months but concerns about first-line resistance additional to rifampicin hampered global uptake. After conditional approval in 2012, the novel agent bedaquiline was demonstrated to improve outcomes and reduce mortality when used in longer and shorter regimens, resulting in the replacement of injectable agents. In the last 2 years, clinical trials of all-oral 6-month three or four drug regimens containing bedaquiline, pretomanid and linezolid have shown superior efficacy against both longer and shorter traditional regimens, resulting in major changes in WHO guidance. SUMMARY Although some concerns around safety and emergent bedaquiline resistance remain to be fully addressed, 6-month all oral regimens promise to transform the treatment of people with MDR-TB worldwide.
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21
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Hughes J, Nielsen J, Buck WC, Mutemba C, Garcia-Prats AJ. QT Interval Prolongation and Second-line Antituberculosis Medicines in Children: An Update and Practical Considerations for Noncardiologists. Pediatr Infect Dis J 2023; 42:e80-e83. [PMID: 36749926 DOI: 10.1097/inf.0000000000003742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Jennifer Hughes
- Department of Pediatrics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - James Nielsen
- National TB Control Program, Mozambique Ministry of Health, Maputo, Mozambique
| | - W Chris Buck
- Department of Pediatrics, University of California Los Angeles David Geffen School of Medicine, Maputo, Mozambique
| | - Criménia Mutemba
- New York University Grossman School of Medicine, New York, New York
| | - Anthony J Garcia-Prats
- Department of Pediatrics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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22
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Mehta K, Guo T, van der Graaf PH, van Hasselt JGC. Predictions of Bedaquiline and Pretomanid Target Attainment in Lung Lesions of Tuberculosis Patients using Translational Minimal Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2023; 62:519-532. [PMID: 36802057 PMCID: PMC10042768 DOI: 10.1007/s40262-023-01217-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Site-of-action concentrations for bedaquiline and pretomanid from tuberculosis patients are unavailable. The objective of this work was to predict bedaquiline and pretomanid site-of-action exposures using a translational minimal physiologically based pharmacokinetic (mPBPK) approach to understand the probability of target attainment (PTA). METHODS A general translational mPBPK framework for the prediction of lung and lung lesion exposure was developed and validated using pyrazinamide site-of-action data from mice and humans. We then implemented the framework for bedaquiline and pretomanid. Simulations were conducted to predict site-of-action exposures following standard bedaquiline and pretomanid, and bedaquiline once-daily dosing. Probabilities of average concentrations within lesions and lungs greater than the minimum bactericidal concentration for non-replicating (MBCNR) and replicating (MBCR) bacteria were calculated. Effects of patient-specific differences on target attainment were evaluated. RESULTS The translational modeling approach was successful in predicting pyrazinamide lung concentrations from mice to patients. We predicted that 94% and 53% of patients would attain bedaquiline average daily PK exposure within lesions (Cavg-lesion) > MBCNR during the extensive phase of bedaquiline standard (2 weeks) and once-daily (8 weeks) dosing, respectively. Less than 5% of patients were predicted to achieve Cavg-lesion > MBCNR during the continuation phase of bedaquiline or pretomanid treatment, and more than 80% of patients were predicted to achieve Cavg-lung >MBCR for all simulated dosing regimens of bedaquiline and pretomanid. CONCLUSIONS The translational mPBPK model predicted that the standard bedaquiline continuation phase and standard pretomanid dosing may not achieve optimal exposures to eradicate non-replicating bacteria in most patients.
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Affiliation(s)
- Krina Mehta
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Tingjie Guo
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Piet H. van der Graaf
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Certara, Canterbury, UK
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23
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Aguilar Diaz JM, Abulfathi AA, te Brake LHM, van Ingen J, Kuipers S, Magis-Escurra C, Raaijmakers J, Svensson EM, Boeree MJ. New and Repurposed Drugs for the Treatment of Active Tuberculosis: An Update for Clinicians. Respiration 2023; 102:83-100. [PMID: 36516792 PMCID: PMC9932851 DOI: 10.1159/000528274] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/28/2022] [Indexed: 12/15/2022] Open
Abstract
Although tuberculosis (TB) is preventable and curable, the lengthy treatment (generally 6 months), poor patient adherence, high inter-individual variability in pharmacokinetics (PK), emergence of drug resistance, presence of comorbidities, and adverse drug reactions complicate TB therapy and drive the need for new drugs and/or regimens. Hence, new compounds are being developed, available drugs are repurposed, and the dosing of existing drugs is optimized, resulting in the largest drug development portfolio in TB history. This review highlights a selection of clinically available drug candidates that could be part of future TB regimens, including bedaquiline, delamanid, pretomanid, linezolid, clofazimine, optimized (high dose) rifampicin, rifapentine, and para-aminosalicylic acid. The review covers drug development history, preclinical data, PK, and current clinical development.
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Affiliation(s)
- Jessica M Aguilar Diaz
- Radboudumc Center for Infectious Diseases, Department of Pulmonary Diseases, TB Expert Center Dekkerswald, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ahmed A Abulfathi
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, Lake Nona (Orlando), University of Florida, Gainesville, Florida, USA,Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria,Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lindsey HM te Brake
- Radboudumc Center for Infectious Diseases, Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jakko van Ingen
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia Kuipers
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cecile Magis-Escurra
- Radboudumc Center for Infectious Diseases, Department of Pulmonary Diseases, TB Expert Center Dekkerswald, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelmer Raaijmakers
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboudumc Center for Infectious Diseases, Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Martin J Boeree
- Radboudumc Center for Infectious Diseases, Department of Pulmonary Diseases, TB Expert Center Dekkerswald, Radboud University Medical Center, Nijmegen, The Netherlands,*Martin J. Boeree,
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24
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Cardiovascular Involvement in Tuberculosis: From Pathophysiology to Diagnosis and Complications-A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13030432. [PMID: 36766543 PMCID: PMC9914020 DOI: 10.3390/diagnostics13030432] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
Although primarily a lung disease, extra-pulmonary tuberculosis (TB) can affect any organ or system. Of these, cardiovascular complications associated with disease or drug toxicity significantly worsen the prognosis. Approximately 60% of patients with TB have a cardiovascular disease, the most common associated pathological entities being pericarditis, myocarditis, and coronary artery disease. We searched the electronic databases PubMed, MEDLINE, and EMBASE for studies that evaluated the impact of TB on the cardiovascular system, from pathophysiological mechanisms to clinical and paraclinical diagnosis of cardiovascular involvement as well as the management of cardiotoxicity associated with antituberculosis medication. The occurrence of pericarditis in all its forms and the possibility of developing constrictive pericarditis, the association of concomitant myocarditis with severe systolic dysfunction and complication with acute heart failure phenomena, and the long-term development of aortic aneurysms with risk of complications, as well as drug-induced toxicity, pose complex additional problems in the management of patients with TB. In the era of multidisciplinarity and polymedication, evidence-based medicine provides various tools that facilitate an integrative management that allows early diagnosis and treatment of cardiac pathologies associated with TB.
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25
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Putra ON, Yulistiani Y, Soedarsono S, Subay S. Favorable outcome of individual regimens containing bedaquiline and delamanid in drug-resistant tuberculosis: A systematic review. Int J Mycobacteriol 2023; 12:1-9. [PMID: 36926755 DOI: 10.4103/ijmy.ijmy_217_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background Drug-resistant tuberculosis (DR-TB) is a public health concern that is difficult to treat, requiring long and complex treatment with highly effective drugs. Bedaquiline and/or delamanid have already shown promising outcomes in patients with DR-TB, increasing the rate of culture conversion and lowering TB-related mortality. Methods We comprehensively searched and evaluated the effectiveness of individual regimens containing bedaquiline and delamanid on culture conversion and treatment success. We assessed for quality either observational or experimental studies. Results We identified 14 studies that met the inclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart with 12 observational and 2 experimental studies. Of 1691 DR-TB patients enrolled in the included studies, 1407 of them concomitantly received regimens containing bedaquiline and delamanid. Overall multidrug resistant (MDR), preextensively drug resistant (XDR), and XDR-TB were seen in 21.4%, 44.1%, and 34.5%, respectively. Of 14 studies, 8 of them reported favorable outcomes including sputum culture conversion and cure rate at the end of treatment, meanwhile 6 studies only reported sputum culture conversion. Sputum culture conversion at the end of the 6th month was 63.6%-94.7% for observational studies, and 87.6%-95.0% for experimental studies. The favorable outcome at the end of treatment was 67.5%-91.4%. With high pre-XDR and XDR cases among DR-TB patients with limited treatment options, regimens containing bedaquiline and delamanid provide successful treatment. Conclusion In DR-TB patients receiving regimens containing bedaquiline and delamanid, favorable outcomes were high including sputum conversion and cure rate.
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Affiliation(s)
- Oki Nugraha Putra
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University; Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | - Yulistiani Yulistiani
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | - Soedarsono Soedarsono
- Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University; Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Susi Subay
- Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
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26
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Dookie N, Ngema SL, Perumal R, Naicker N, Padayatchi N, Naidoo K. The Changing Paradigm of Drug-Resistant Tuberculosis Treatment: Successes, Pitfalls, and Future Perspectives. Clin Microbiol Rev 2022; 35:e0018019. [PMID: 36200885 PMCID: PMC9769521 DOI: 10.1128/cmr.00180-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) remains a global crisis due to the increasing incidence of drug-resistant forms of the disease, gaps in detection and prevention, models of care, and limited treatment options. The DR-TB treatment landscape has evolved over the last 10 years. Recent developments include the remarkable activity demonstrated by the newly approved anti-TB drugs bedaquiline and pretomanid against Mycobacterium tuberculosis. Hence, treatment of DR-TB has drastically evolved with the introduction of the short-course regimen for multidrug-resistant TB (MDR-TB), transitioning to injection-free regimens and the approval of the 6-month short regimens for rifampin-resistant TB and MDR-TB. Moreover, numerous clinical trials are under way with the aim to reduce pill burden and shorten the DR-TB treatment duration. While there have been apparent successes in the field, some challenges remain. These include the ongoing inclusion of high-dose isoniazid in DR-TB regimens despite a lack of evidence for its efficacy and the inclusion of ethambutol and pyrazinamide in the standard short regimen despite known high levels of background resistance to both drugs. Furthermore, antimicrobial heteroresistance, extensive cavitary disease and intracavitary gradients, the emergence of bedaquiline resistance, and the lack of biomarkers to monitor DR-TB treatment response remain serious challenges to the sustained successes. In this review, we outline the impact of the new drugs and regimens on patient treatment outcomes, explore evidence underpinning current practices on regimen selection and duration, reflect on the disappointments and pitfalls in the field, and highlight key areas that require continued efforts toward improving treatment approaches and rapid biomarkers for monitoring treatment response.
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Affiliation(s)
- Navisha Dookie
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Senamile L. Ngema
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Rubeshan Perumal
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nikita Naicker
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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27
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Edwards BD, Field SK. The Struggle to End a Millennia-Long Pandemic: Novel Candidate and Repurposed Drugs for the Treatment of Tuberculosis. Drugs 2022; 82:1695-1715. [PMID: 36479687 PMCID: PMC9734533 DOI: 10.1007/s40265-022-01817-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
This article provides an encompassing review of the current pipeline of putative and developed treatments for tuberculosis, including multidrug-resistant strains. The review has organized each compound according to its site of activity. To provide context, mention of drugs within current recommended treatment regimens is made, thereafter followed by discussion on recently developed and upcoming molecules at established and novel targets. The review is designed to provide a clinically applicable understanding of the compounds that are deemed most currently relevant, including those already under clinical study and those that have shown promising pre-clinical results. An extensive review of the efficacy and safety data for key contemporary drugs already incorporated into treatment regimens, such as bedaquiline, pretomanid, and linezolid, is provided. The three levels of the bacterial cell wall (mycolic acid, arabinogalactan, and peptidoglycan layers) are highlighted and important compounds designed to target each layer are delineated. Amongst others, the highly optimistic and potent anti-mycobacterial activity of agents such as BTZ-043, PBTZ 169, and OPC-167832 are emphasized. The evolving spectrum of oxazolidinones, such as sutezolid, delpazolid, and TBI-223, all aiming to exceed the efficacy achieved with linezolid yet offer a safer alternative to the potential toxicity, are reviewed. New and exciting prospective agents with novel mechanisms of impact against TB, including 3-aminomethyl benzoxaboroles and telacebec, are underscored. We describe new diaryloquinolines in development, striving to build on the immense success of bedaquiline. Finally, we discuss some of these compounds that have shown encouraging additive or synergistic benefit when used in combination, providing some promise for the future in treating this ancient scourge.
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Affiliation(s)
- Brett D Edwards
- Division of Infectious Diseases and Tuberculosis Services, Alberta Health Services, Department of Medicine, Cumming School of Medicine, University of Calgary, Peter Lougheed Centre, 3500, 26 Avenue NE, Calgary, AB, T1Y6J4, Canada.
| | - Stephen K Field
- Division of Infectious Diseases and Tuberculosis Services, Alberta Health Services, Department of Medicine, Cumming School of Medicine, University of Calgary, Peter Lougheed Centre, 3500, 26 Avenue NE, Calgary, AB, T1Y6J4, Canada
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Chen W, Lin W, Yu N, Zhang L, Wu Z, Chen Y, Li Z, Gong F, Li N, Chen X, He X, Wu Y, Zeng X, Yueh Y, Xu R, Ji G. Activation of Dynamin-Related Protein 1 and Induction of Mitochondrial Apoptosis by Exosome-Rifampicin Nanoparticles Exerts Anti-Osteosarcoma Effect. Int J Nanomedicine 2022; 17:5431-5446. [PMID: 36426375 PMCID: PMC9680970 DOI: 10.2147/ijn.s379917] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/12/2022] [Indexed: 09/07/2023] Open
Abstract
PURPOSE To investigate induction of cell death in Osteosarcoma (OS) using the anti-tuberculosis drug, rifampicin, loaded into exosomes. PATIENTS AND METHODS BMSC-exosomes were isolated by ultracentrifugation and loaded ultrasonically with rifampicin. Nanoparticle exosome-rifampicin (EXO-RIF) was added to the OS cell-lines, 143B and MG63, in vitro, to observe the growth inhibitory effect. In vivo experiments were conducted by injecting fluorescently labeled EXO-RIF through the tail vein of 143B cell xenograft nude mice and tracking distribution. Therapeutic and toxic side-effects were analyzed systemically. RESULTS Sonication resulted in encapsulation of rifampicin into exosomes. Exosome treatment accelerated the entry of rifampicin into OS cells and enhanced the actions of rifampicin in inhibiting OS proliferation, migration and invasion. Cell cycle arrest at the G2/M phase was observed. Dynamin-related protein 1 (Drp1) was activated by EXO-RIF and caused mitochondrial lysis and apoptosis. Exosome treatment targeted rifampicin to the site of OS, causing OS apoptosis and improving mouse survival in vivo. CONCLUSION The potent Drp1 agonist, rifampicin, induced OS apoptosis and exosome loading, improving OS targeting and mouse survival rates. EXO-RIF is a promising strategy for the treatment of diverse malignancies.
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Affiliation(s)
- Wenkai Chen
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Wenping Lin
- Department of Spine Surgery, Shenzhen Pingle Orthopedic Hospital, Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| | - Naichun Yu
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Linlin Zhang
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Zuoxing Wu
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Yongjie Chen
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Zongguang Li
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Fengqing Gong
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Na Li
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Xiaohui Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Xu He
- Department of Spine Surgery, Shenzhen Pingle Orthopedic Hospital, Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| | - Yue Wu
- Department of Pathology, Zhongshan Hospital, Xiamen University, Xiamen, People’s Republic of China
| | - Xiangchen Zeng
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Yuting Yueh
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Ren Xu
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Department of Orthopedic Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
- Collaborative Innovation Centre of Regenerative Medicine and Medical BioResource Development and Application Co-Constructed by the Province and Ministry, Guangxi Medical University, Nanning, People’s Republic of China
| | - Guangrong Ji
- Department of Orthopedic Surgery, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
- Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Xiamen Key Laboratory of Regeneration Medicine, Organ Transplantation Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
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Muacevic A, Adler JR. Grade III Severe QT Prolongation in an Indian Male on All-Oral Longer Regimen for Multidrug-Resistant Pulmonary Tuberculosis: World's First Case. Cureus 2022; 14:e31819. [PMID: 36579197 PMCID: PMC9788793 DOI: 10.7759/cureus.31819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 11/24/2022] Open
Abstract
Antitubercular drugs are associated with several adverse drug reactions (ADRs). Some of these ADRs are life-threatening and require immediate attention and hospital admission. With the development of new regimens and inclusions of newer drugs such as bedaquiline, pretomanid, and delamanid, it is imperative to have an eye for the side effects. A number of antitubercular drugs such as bedaquiline, moxifloxacin, clofazimine, pretomanid, and delamanid are known to cause ADRs on the heart. Herein, a case of grade III severe QT prolongation with corrected QT (QTc) of 688 ms in an Indian male on a WHO-recommended all-oral longer regimen (AOLR) for multidrug-resistant (MDR) pulmonary tuberculosis (TB) is presented. This episode happened on the sixth day post his treatment initiation, thereby making it the earliest of such findings. The patient was managed conservatively, and his baseline electrocardiogram (ECG) returned to normal with QTc of 432 ms with the offending drug as moxifloxacin, which was omitted from the regimen and replaced with delamanid. There are some cases similar to this case available in the literature; however, grade III severe QT prolongation with QTc of 688 ms in a male on a WHO-recommended all-oral longer regimen for multidrug-resistant pulmonary tuberculosis is never reported.
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Schaberg T, Brinkmann F, Feiterna-Sperling C, Geerdes-Fenge H, Hartmann P, Häcker B, Hauer B, Haas W, Heyckendorf J, Lange C, Maurer FP, Nienhaus A, Otto-Knapp R, Priwitzer M, Richter E, Salzer HJ, Schoch O, Schönfeld N, Stahlmann R, Bauer T. Tuberkulose im Erwachsenenalter. Pneumologie 2022; 76:727-819. [DOI: 10.1055/a-1934-8303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungDie Tuberkulose ist in Deutschland eine seltene, überwiegend gut behandelbare Erkrankung. Weltweit ist sie eine der häufigsten Infektionserkrankungen mit ca. 10 Millionen Neuerkrankungen/Jahr. Auch bei einer niedrigen Inzidenz in Deutschland bleibt Tuberkulose insbesondere aufgrund der internationalen Entwicklungen und Migrationsbewegungen eine wichtige Differenzialdiagnose. In Deutschland besteht, aufgrund der niedrigen Prävalenz der Erkrankung und der damit verbundenen abnehmenden klinischen Erfahrung, ein Informationsbedarf zu allen Aspekten der Tuberkulose und ihrer Kontrolle. Diese Leitlinie umfasst die mikrobiologische Diagnostik, die Grundprinzipien der Standardtherapie, die Behandlung verschiedener Organmanifestationen, den Umgang mit typischen unerwünschten Arzneimittelwirkungen, die Besonderheiten in der Diagnostik und Therapie resistenter Tuberkulose sowie die Behandlung bei TB-HIV-Koinfektion. Sie geht darüber hinaus auf Versorgungsaspekte und gesetzliche Regelungen wie auch auf die Diagnosestellung und präventive Therapie einer latenten tuberkulösen Infektion ein. Es wird ausgeführt, wann es der Behandlung durch spezialisierte Zentren bedarf.Die Aktualisierung der S2k-Leitlinie „Tuberkulose im Erwachsenenalter“ soll allen in der Tuberkuloseversorgung Tätigen als Richtschnur für die Prävention, die Diagnose und die Therapie der Tuberkulose dienen und helfen, den heutigen Herausforderungen im Umgang mit Tuberkulose in Deutschland gewachsen zu sein.
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Affiliation(s)
- Tom Schaberg
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | - Folke Brinkmann
- Abteilung für pädiatrische Pneumologie/CF-Zentrum, Universitätskinderklinik der Ruhr-Universität Bochum, Bochum
| | - Cornelia Feiterna-Sperling
- Klinik für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und Intensivmedizin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin
| | | | - Pia Hartmann
- Labor Dr. Wisplinghoff Köln, Klinische Infektiologie, Köln
- Department für Klinische Infektiologie, St. Vinzenz-Hospital, Köln
| | - Brit Häcker
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | - Jan Heyckendorf
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Christoph Lange
- Klinische Infektiologie, Forschungszentrum Borstel
- Deutsches Zentrum für Infektionsforschung (DZIF), Standort Hamburg-Lübeck-Borstel-Riems
- Respiratory Medicine and International Health, Universität zu Lübeck, Lübeck
- Baylor College of Medicine and Texas Childrenʼs Hospital, Global TB Program, Houston, TX, USA
| | - Florian P. Maurer
- Nationales Referenzzentrum für Mykobakterien, Forschungszentrum Borstel, Borstel
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Albert Nienhaus
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg
| | - Ralf Otto-Knapp
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | | | | | | | - Ralf Stahlmann
- Institut für klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin, Berlin
| | - Torsten Bauer
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
- Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin
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Nasiri MJ, Zangiabadian M, Arabpour E, Amini S, Khalili F, Centis R, D'Ambrosio L, Denholm JT, Schaaf HS, van den Boom M, Kurhasani X, Dalcolmo MP, Al-Abri S, Chakaya J, Alffenaar JW, Akkerman O, Silva DR, Muňoz-Torrico M, Seaworth B, Pontali E, Saderi L, Tiberi S, Zumla A, Migliori GB, Sotgiu G. Delamanid-containing regimens and multidrug-resistant tuberculosis: A systematic review and meta-analysis. Int J Infect Dis 2022; 124 Suppl 1:S90-S103. [PMID: 35245659 PMCID: PMC9731904 DOI: 10.1016/j.ijid.2022.02.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/20/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Multidrug-resistant tuberculosis (MDR-TB) is a life-threatening condition needing long poly-chemotherapy regimens. As no systematic reviews/meta-analysis is available to comprehensively evaluate the role of delamanid (DLM), we evaluated its effectiveness and safety. METHODS We reviewed the relevant scientific literature published up to January 20, 2022. The pooled success treatment rate with 95% confidence intervals (CI) was assessed using a random-effect model. We assessed studies for quality and bias, and considered P<0.05 to be statistically significant. RESULTS After reviewing 626 records, we identified 25 studies that met the inclusion criteria, 22 observational and 3 experimental, with 1276 and 411 patients, respectively. In observational studies the overall pooled treatment success rate of DLM-containing regimens was 80.9% (95% CI 72.6-87.2) with no evidence of publication bias (Begg's test; P >0.05). The overall pooled treatment success rate in DLM and bedaquiline-containing regimens was 75.2% (95% CI 68.1-81.1) with no evidence of publication bias (Begg's test; P >0.05). In experimental studies the pooled treatment success rate of DLM-containing regimens was 72.5 (95% CI 44.2-89.8, P <0.001, I2: 95.1%) with no evidence of publication bias (Begg's test; P >0.05). CONCLUSIONS In MDR-TB patients receiving DLM, culture conversion and treatment success rates were high despite extensive resistance with limited adverse events.
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Affiliation(s)
- Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moein Zangiabadian
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Erfan Arabpour
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sirus Amini
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farima Khalili
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | | | - Justin T. Denholm
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia,Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martin van den Boom
- World Health Organization Regional Office for the Eastern Mediterranean Region, Cairo, Egypt
| | | | | | - Seif Al-Abri
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Jeremiah Chakaya
- Department of Medicine, dermatology and therapeutics, Kenyatta University, Nairobi, Kenya,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jan-Willem Alffenaar
- Sydney Institute of Infectious Diseases, University of Sydney, Sydney, NSW, Australia,School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia
| | - Onno Akkerman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands,University of Groningen, University Medical Center Groningen, Tuberculosis center Beatrixoord, Haren, the Netherlands
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcela Muňoz-Torrico
- Tuberculosis clinic, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico
| | - Barbara Seaworth
- Department of Medicine University of Texas Health Science Center, Tyler, Texas
| | - Emanuele Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | - Laura Saderi
- Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
| | - Simon Tiberi
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, United Kingdom,National Institute for Health Research Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy,Address for correspondence: Giovanni Battista Migliori, Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Via Roncaccio 16, Tradate, Varese, 21049, Italy.
| | - Giovanni Sotgiu
- Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
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Putra ON, Yulistiani Y, Soedarsono S. Scoping review: QT interval prolongation in regimen containing bedaquiline and delamanid in patients with drug-resistant tuberculosis. Int J Mycobacteriol 2022; 11:349-355. [PMID: 36510917 DOI: 10.4103/ijmy.ijmy_178_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background A regimen containing bedaquiline-delamanid is recommended in management of drug-resistant tuberculosis (DR TB) to increase a success rate. However, this regimen was rare in a clinical setting due to a potential risk of QT prolongation. Several studies have reported the incidence of QT prolongation after administration of this regimen, but the results are inconsistent due to different sample size, study design, and covariate. The aim of this review is to summarize and analyze the published articles related to QT prolongation of bedaquiline and delamanid in PubMed and ScienceDirect databases using a scoping review. Methods This scoping review was conducted under PRISMA for scoping review. The outcomes of this review were incidence of QT prolongation and death. We found 8 articles to be included in this review. Results The incidence of QT prolongation was higher for DR TB patients who received a regimen containing bedaquiline and delamanid. However, this review found no clinical symptoms, such as cardiac arrhythmias, torsade de pointes, or even death. DR TB patients, especially the elderly, were at risk for QT prolongation. Special consideration in patients with HIV and low level of potassium should be closely monitored for QT interval. Conclusion The regular measurement of electrocardiography was highly recommended to evaluate QT interval. Generally, the use of individualized regimen containing bedaquiline and delamanid is relatively safe in DR TB patients.
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Affiliation(s)
- Oki Nugraha Putra
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University; Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | | | - Soedarsono Soedarsono
- Faculty of Medicine, Hang Tuah University; Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
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Tanneau L, Karlsson MO, Rosenkranz SL, Cramer YS, Shenje J, Upton CM, Morganroth J, Diacon AH, Maartens G, Dooley KE, Svensson EM. Assessing Prolongation of the Corrected QT Interval with Bedaquiline and Delamanid Coadministration to Predict the Cardiac Safety of Simplified Dosing Regimens. Clin Pharmacol Ther 2022; 112:873-881. [PMID: 35687528 PMCID: PMC9474693 DOI: 10.1002/cpt.2685] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022]
Abstract
Delamanid and bedaquiline are two drugs approved to treat drug-resistant tuberculosis, and each have been associated with corrected QT interval (QTc) prolongation. We aimed to investigate the relationships between the drugs' plasma concentrations and the prolongation of observed QT interval corrected using Fridericia's formula (QTcF) and to evaluate their combined effects on QTcF, using a model-based population approach. Furthermore, we predicted the safety profiles of once daily regimens. Data were obtained from a trial where participants were randomized 1:1:1 to receive delamanid, bedaquiline, or delamanid + bedaquiline. The effect on QTcF of delamanid and/or its metabolite (DM-6705) and the pharmacodynamic interactions under coadministration were explored based on a published model between bedaquiline's metabolite (M2) and QTcF. The metabolites of each drug were found to be responsible for the drug-related QTcF prolongation. The final drug-effect model included a competitive interaction between M2 and DM-6705 acting on the same cardiac receptor and thereby reducing each other's apparent potency, by 28% (95% confidence interval (CI), 22-40%) for M2 and 33% (95% CI, 24-54%) for DM-6705. The generated combined effect was not greater but close to "additivity" in the analyzed concentration range. Predictions with the final model suggested a similar QT prolonging potential with simplified, once-daily dosing regimens compared with the approved regimens, with a maximum median change from baseline QTcF increase of 20 milliseconds in both regimens. The concentrations-QTcF relationship of the combination of bedaquiline and delamanid was best described by a competitive binding model involving the two main metabolites. Model predictions demonstrated that QTcF prolongation with simplified once daily regimens would be comparable to currently used dosing regimens.
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Affiliation(s)
| | | | | | | | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, University of Cape TownCape TownSouth Africa
| | | | | | | | - Gary Maartens
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Kelly E. Dooley
- Center for Tuberculosis ResearchJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elin M. Svensson
- Department of PharmacyUppsala UniversityUppsalaSweden
- Department of Pharmacy, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
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Abstract
Mycobacterium tuberculosis, the causative agent of tuberculosis (TB), continues to pose a major public health problem and is the leading cause of mortality in people infected with human immunodeficiency virus (HIV). HIV infection greatly increases the risk of developing TB even before CD4+ T-cell counts decrease. Co-infection provides reciprocal advantages to both pathogens and leads to acceleration of both diseases. In HIV-coinfected persons, the diagnosis and treatment of tuberculosis are particularly challenging. Intensifying integration of HIV and tuberculosis control programmes has an impact on reducing diagnostic delays, increasing early case detection, providing prompt treatment onset, and ultimately reducing transmission. In this Review, we describe our current understanding of how these two pathogens interact with each other, new sensitive rapid assays for TB, several new prevention methods, new drugs and regimens.
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Affiliation(s)
- Qiaoli Yang
- Department of Infectious Diseases, Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Jinjin Han
- Department of Infectious Diseases, Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Jingjing Shen
- Department of Infectious Diseases, Changzhi people’s Hospital, Changzhi, Shanxi Province, China
| | - Xinsen Peng
- Department of Cardiology, Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Lurong Zhou
- Department of Infectious Diseases, Changzhi Medical College, Changzhi, Shanxi Province, China
- *Correspondence: Lurong Zhou, Vice President, Chief Physician, Professor, Department of Infectious Diseases, Changzhi People’s Hospital, No.502 Changzhi Middle Road, Changzhi 046000, Shanxi Province, China. (e-mail: )
| | - Xuejing Yin
- Department of Neurology, Changzhi Medical College, Changzhi, Shanxi Province, China
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Gobis K, Szczesio M, Olczak A, Mazerant-Politowicz I, Ziembicka D, Pacholczyk-Sienicka B, Augustynowicz-Kopeć E, Głogowska A, Korona-Głowniak I, Fruziński A. N'-Substituted 4-Phenylpicolinohydrazonamides with Thiosemicarbazone Moiety as New Potential Antitubercular Agents: Synthesis, Structure and Evaluation of Antimicrobial Activity. MATERIALS (BASEL, SWITZERLAND) 2022; 15:ma15165513. [PMID: 36013649 PMCID: PMC9414056 DOI: 10.3390/ma15165513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 06/01/2023]
Abstract
Three new 4-phenylpicolin derivatives with a thiosemicarbazone structure were synthesized and evaluated for tuberculostatic activity. The compounds were obtained by the condensation of methyl 4-phenylpicolonimidate with the corresponding cycloalkylamino-1-carbothiohydrazides. The 1H NMR temperature spectra obtained showed proton lability at the nitrogen atom N2, and X-ray crystallography confirmed the zwitterionic structure of all products. ADME calculations indicate that the compounds can be tested as future drugs. All compounds were absorbed in the gastrointestinal tract. All compounds also showed very good tuberculostatic activity (MIC 3.1-12.5 µg/mL). Derivative 1b showed the best selectivity for M. tuberculosis compared to the other pathogenic species tested. The study has allowed the emergence of imine derivative 1b as a good structure for further optimization in the search for antitubercular drugs.
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Affiliation(s)
- Katarzyna Gobis
- Department of Organic Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, 107 Gen. Hallera Ave., 80-416 Gdańsk, Poland
| | - Małgorzata Szczesio
- Institute of General and Ecological Chemistry, Faculty of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Andrzej Olczak
- Institute of General and Ecological Chemistry, Faculty of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Ida Mazerant-Politowicz
- Institute of General and Ecological Chemistry, Faculty of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Dagmara Ziembicka
- Department of Organic Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, 107 Gen. Hallera Ave., 80-416 Gdańsk, Poland
| | | | - Ewa Augustynowicz-Kopeć
- Department of Microbiology, Institute of Tuberculosis and Pulmonary Diseases, 26 Płocka Str., 01-138 Warsaw, Poland
| | - Agnieszka Głogowska
- Department of Microbiology, Institute of Tuberculosis and Pulmonary Diseases, 26 Płocka Str., 01-138 Warsaw, Poland
| | - Izabela Korona-Głowniak
- Department of Pharmaceutical Microbiology, Faculty of Pharmacy, Medical University of Lublin, 1 Chodźki Street, 20-093 Lublin, Poland
| | - Andrzej Fruziński
- Institute of General and Ecological Chemistry, Faculty of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
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Wu IL, Chitnis AS, Jaganath D. A narrative review of tuberculosis in the United States among persons aged 65 years and older. J Clin Tuberc Other Mycobact Dis 2022; 28:100321. [PMID: 35757390 PMCID: PMC9213239 DOI: 10.1016/j.jctube.2022.100321] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022] Open
Abstract
Tuberculosis (TB) is a preventable infectious disease that confers significant morbidity, mortality, and psychosocial challenges. As TB incidence in the United States (U.S.) decreased from 9.7/100,000 to 2.2/100,000 from 1993 to 2020, the proportion of cases occurring among adults aged 65 and older increased. We conducted a review of published literature in the U.S. and other similar low-TB-burden settings to characterize the epidemiology and unique diagnostic challenges of TB in older adults. This narrative review also provides an overview of treatment characteristics, outcomes, and research gaps in this patient population. Older adults had a 30% higher likelihood of delayed TB diagnosis, with contributing factors such as acid-fast bacilli sputum smear-negative disease (56%) and non-classical clinical presentation. At least 90% of TB cases among older adults resulted from reactivation of latent TB infection (LTBI), but guidance around when to screen and treat LTBI in these patients is lacking. In addition, routine TB testing methods such as interferon-gamma release assays were two times more likely to have false-negative results among older adults. Advanced age was also often accompanied by complex comorbidities and impaired drug metabolism, increasing the risk of treatment failure (23%) and death (19%). A greater understanding of the unique factors of TB among older adults will inform clinical and public health efforts to improve outcomes in this complex patient population and TB control in the U.S.
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Affiliation(s)
- Iris L Wu
- School of Public Health, University of California, Berkeley, Berkeley, CA, United States.,School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Amit S Chitnis
- Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, CA, United States
| | - Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California, San Francisco, San Francisco, CA, United States.,Center for Tuberculosis, University of California, San Francisco, CA, United States
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Tanneau L, Karlsson MO, Diacon AH, Shenje J, De Los Rios J, Wiesner L, Upton CM, Dooley KE, Maartens G, Svensson EM. Population Pharmacokinetics of Delamanid and its Main Metabolite DM-6705 in Drug-Resistant Tuberculosis Patients Receiving Delamanid Alone or Coadministered with Bedaquiline. Clin Pharmacokinet 2022; 61:1177-1185. [PMID: 35668346 PMCID: PMC9349160 DOI: 10.1007/s40262-022-01133-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Delamanid is a nitroimidazole, a novel class of drug for treating tuberculosis, and is primarily metabolized by albumin into the metabolite DM-6705. The aims of this analysis were to develop a population pharmacokinetic (PK) model to characterize the concentration-time course of delamanid and DM-6705 in adults with drug-resistant tuberculosis and to explore a potential drug-drug interaction with bedaquiline when coadministered. METHODS Delamanid and DM-6705 concentrations after oral administration, from 52 participants (of whom 26 took bedaquiline concurrently and 20 were HIV-1 positive) enrolled in the DELIBERATE trial were analyzed using nonlinear mixed-effects modeling. RESULTS Delamanid PK were described by a one-compartment disposition model with transit compartment absorption (mean absorption time of 1.45 h [95% confidence interval 0.501-2.20]) and linear elimination, while the PK of DM-6705 metabolite were described by a one-compartment disposition model with delamanid clearance as input and linear elimination. Predicted terminal half-life values for delamanid and DM-6705 were 15.1 h and 7.8 days, respectively. The impact of plasma albumin concentrations on delamanid metabolism was not significant. Bedaquiline coadministration did not affect delamanid PK. Other than allometric scaling with body weight, no patients' demographics were significant (including HIV). CONCLUSIONS This is the first joint PK model of delamanid and its DM-6705 metabolite. As such, it can be utilized in future exposure-response or exposure-safety analyses. Importantly, albumin concentrations, bedaquiline coadministration, and HIV co-infection (dolutegravir coadministration) did not have an effect on delamanid and DM-6705 PK.
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Affiliation(s)
- Lénaïg Tanneau
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | | | - Justin Shenje
- SATVI, University of Cape Town, Cape Town, South Africa
| | - Jorge De Los Rios
- Barranco Clinical Research Site, Asociacion Civil Impacta Salud y Educacion, Lima, Peru
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
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Padmapriyadarsini C, Vohra V, Bhatnagar A, Solanki R, Sridhar R, Anande L, Muthuvijaylakshmi M, Rana MB, Jeyadeepa B, Taneja G, Balaji S, Shah P, Saravanan N, Chavan V, Kumar H, Ponnuraja C, Livchits V, Bahl M, Alavadi U, Sachdeva KS, Swaminathan S. Bedaquiline, Delamanid, Linezolid and Clofazimine for Treatment of Pre-extensively Drug-Resistant Tuberculosis. Clin Infect Dis 2022; 76:ciac528. [PMID: 35767251 PMCID: PMC9907500 DOI: 10.1093/cid/ciac528] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/18/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment success rates for multidrug-resistant tuberculosis (MDR-TB) remain low globally. Availability of newer drugs has given scope to develop regimens that can be patient-friendly, less toxic, with improved outcomes. We proposed to determine the effectiveness of an entirely oral, short-course regimen with Bedaquiline and Delamanid in treating MDR-TB with additional resistance to fluoroquinolones (MDR-TBFQ+) or second-line injectable (MDR-TBSLI+). METHODS We prospectively determined the effectiveness and safety of combining two new drugs with two repurposed drugs - Bedaquiline, Delamanid, Linezolid, and Clofazimine for 24-36 weeks in adults with pulmonary MDR-TBFQ+ or/and MDR-TBSLI+. The primary outcome was a favorable response at end of treatment, defined as two consecutive negative cultures taken four weeks apart. The unfavorable outcomes included bacteriologic or clinical failure during treatment period. RESULTS Of the 165 participants enrolled, 158 had MDR-TBFQ+. At the end of treatment, after excluding 12 patients due to baseline drug susceptibility and culture negatives, 139 of 153 patients (91%) had a favorable outcome. Fourteen patients (9%) had unfavorable outcomes: four deaths, seven treatment changes, two bacteriological failures, and one withdrawal. During treatment, 85 patients (52%) developed myelosuppression, 69 (42%) reported peripheral neuropathy, and none had QTc(F) prolongation >500msec. At 48 weeks of follow-up, 131 patients showed sustained treatment success with the resolution of adverse events in the majority. CONCLUSION After 24-36 weeks of treatment, this regimen resulted in a satisfactory favorable outcome in pulmonary MDR-TB patients with additional drug resistance. Cardiotoxicity was minimal, and myelosuppression, while common, was detected early and treated successfully.
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Affiliation(s)
| | - Vikram Vohra
- National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Anuj Bhatnagar
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Delhi, India
| | | | | | | | | | - Meera Bhatia Rana
- National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | | | - Gaurav Taneja
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Delhi, India
| | - S Balaji
- ICMR–National Institute for Research in Tuberculosis, Chennai, India
| | - Prashant Shah
- B. J. Medical College and Hospital, Ahmedabad, India
| | - N Saravanan
- ICMR–National Institute for Research in Tuberculosis, Chennai, India
| | | | - Hemanth Kumar
- ICMR–National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Monica Bahl
- Clinical Development Service Agency, New Delhi, India
| | - Umesh Alavadi
- US Agency for International Development, Washington D.C., USA
| | - K S Sachdeva
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Soumya Swaminathan
- Indian Council of Medical Research, New Delhi, India
- World Health Organization, Geneva, Switzerland
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Mason M, Gregory E, Foster K, Klatt M, Zoubek S, Eid A. Pharmacologic management of Mycobacterium chimaera Infections: A Primer for Clinicians. Open Forum Infect Dis 2022; 9:ofac287. [PMID: 35866101 PMCID: PMC9297092 DOI: 10.1093/ofid/ofac287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022] Open
Abstract
Mycobacterium chimaera, a member of the Mycobacterium avium complex, can cause infections in individuals after open heart surgery due to contaminated heater-cooler units. The diagnosis can be challenging, as the incubation period can be quite variable, and symptoms are nonspecific. In addition to aggressive surgical management, combination pharmacologic therapy is the cornerstone of therapy, which should consist of a macrolide, a rifamycin, ethambutol, and amikacin. Multiple second-line agents may be utilized in the setting of intolerances or toxicities. In vitro susceptibility of these agents is similar to activity against other species in the Mycobacterium avium complex. Drug–drug interactions are frequently encountered, as many individuals have chronic medical comorbidities and are prescribed medications that interact with the first-line agents used to treat M. chimaera. Recognition of these drug–drug interactions and appropriate management are essential for optimizing treatment outcomes.
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Affiliation(s)
- Matt Mason
- The University of Kansas Health System, Department of Pharmacy , Kansas City, KS , USA
| | - Eric Gregory
- The University of Kansas Health System, Department of Pharmacy , Kansas City, KS , USA
| | - Keith Foster
- The University of Kansas Health System, Department of Pharmacy , Kansas City, KS , USA
| | - Megan Klatt
- The University of Kansas Health System, Department of Pharmacy , Kansas City, KS , USA
| | - Sara Zoubek
- The University of Kansas Health System, Department of Pharmacy , Kansas City, KS , USA
| | - Albert Eid
- Kansas University Medical Center, Department of Infectious Diseases , Kansas City, KS , USA
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40
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Upton CM, Steele CI, Maartens G, Diacon AH, Wiesner L, Dooley KE. Pharmacokinetics of bedaquiline in cerebrospinal fluid (CSF) in patients with pulmonary tuberculosis (TB). J Antimicrob Chemother 2022; 77:1720-1724. [PMID: 35257182 PMCID: PMC9633714 DOI: 10.1093/jac/dkac067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/07/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND With current treatment options most patients with CNS TB develop severe disability or die. Drug-resistant tuberculous meningitis is nearly uniformly fatal. Novel treatment strategies are needed. Bedaquiline, a potent anti-TB drug, has been reported to be absent from CSF in a single report. OBJECTIVES To explore the pharmacokinetics of bedaquiline and its M2 metabolite in the CSF of patients with pulmonary TB. PATIENTS AND METHODS Individuals with rifampicin-resistant pulmonary TB established on a 24 week course of treatment with bedaquiline underwent a lumbar puncture along with multiple blood sample collections over 24 h for CSF and plasma pharmacokinetic assessment, respectively. To capture the expected low bedaquiline and M2 concentrations (due to high protein binding in plasma) we optimized CSF collection and storage methods in vitro before concentrations were quantified via liquid chromatography with tandem MS. RESULTS Seven male participants were enrolled, two with HIV coinfection. Using LoBind® tubes lined with a 5% BSA solution, bedaquiline and M2 could be accurately measured in CSF. Bedaquiline and M2 were present in all patients at all timepoints at concentrations similar to the estimated unbound fractions in plasma. CONCLUSIONS Bedaquiline and M2 penetrate freely into the CSF of pulmonary TB patients with a presumably intact blood-brain barrier. Clinical studies are urgently needed to determine whether bedaquiline can contribute meaningfully to the treatment of CNS TB.
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Affiliation(s)
| | - Chanel I Steele
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW Diagnosis and treatment of drug-resistant tuberculosis (DR-TB) is undergoing substantial changes, owing availability of new diagnostic tools and drugs, coupled with global underdiagnosis and undertreatment. Recent developments are reviewed. RECENT FINDINGS Molecular diagnostics, for Mycobacterium tuberculosis complex detection and prediction of drug resistance, implemented in the last decade, accelerated TB diagnosis with improved case detection. Nevertheless, access and coverage of drug-resistance testing remain insufficient. Genome sequencing-technologies, based on targeted next-generation sequencing show early potential to mitigate some of the challenges in the future. The recommendation to use an all oral, bedaquiline based regimen for treatment of multidrug-resistant/rifampicin-resistant TB is major advancement in DR-TB care. TB regimen using new and repurposed TB drugs demonstrate in recent clinical trials like, NIX-TB, ZeNIX and TB PRACTECAL considerable treatment success, shorten treatment duration and reduce toxicity. Their optimal use is threatened by the rapid occurrence and spread of strains, resistant to new drugs. Children benefit only very slowly from the progress. SUMMARY There is notable progress in improved diagnosis and treatment of drug-resistant TB, but complicated by the COVID-19 pandemic the majority of TB patients worldwide don't have (yet) access to the advances.
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Huerga H, Khan U, Bastard M, Mitnick CD, Lachenal N, Khan PY, Seung KJ, Melikyan N, Ahmed S, Rich ML, Varaine F, Osso E, Rashitov M, Salahuddin N, Salia G, Sánchez E, Serobyan A, Siddiqui MR, Tefera DG, Vetushko D, Yeghiazaryan L, Holtzman D, Islam S, Kumsa A, Leblanc GJ, Leonovich O, Mamsa S, Manzur-Ul-Alam M, Myint Z, Padayachee S, Franke MF, Hewison C. Safety and effectiveness outcomes from a 14-country cohort of patients with multi-drug resistant tuberculosis treated concomitantly with bedaquiline, delamanid and other second-line drugs. Clin Infect Dis 2022; 75:1307-1314. [PMID: 35243494 PMCID: PMC9555840 DOI: 10.1093/cid/ciac176] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Concomitant use of bedaquiline (Bdq) and delamanid (Dlm) for multi-drug/rifampicin resistant tuberculosis (MDR/RR-TB) has raised concerns about a potentially poor risk-benefit ratio. Yet this combination is an important alternative for patients infected with strains of TB with complex drug resistance profiles or who cannot tolerate other therapies. We assessed safety and treatment outcomes of MDR/RR-TB patients receiving concomitant Bdq and Dlm, along with other second-line anti-TB drugs. Methods We conducted a multi-centric, prospective observational cohort study across 14 countries among patients receiving concomitant Bdq-Dlm treatment. Patients were recruited between April 2015 and September 2018 and were followed until the end of treatment. All serious adverse events and adverse events of special interest (AESI), leading to a treatment change, or judged significant by a clinician, were systematically monitored and documented. Results Overall, 472 patients received Bdq and Dlm concomitantly. A large majority also received linezolid (89.6%) and clofazimine (84.5%). Nearly all (90.3%) had extensive disease; most (74.2%) had resistance to fluoroquinolones. The most common AESI were peripheral neuropathy (134, 28.4%) and electrolyte depletion (94, 19.9%). Acute kidney injury and myelosuppression were seen in 40 (8.5%) and 24 (5.1%) of patients, respectively. QT prolongation occurred in 7 patients (1.5%). Overall, 78.0% (358/458) had successful treatment outcomes, 8.9% died, and 7.2% experienced treatment failure. Conclusions Concomitant use of Bdq and Dlm, along with linezolid and clofazimine, is safe and effective for MDR/RR-TB patients with extensive disease. Using these drugs concomitantly is a good therapeutic option for patients with resistance to many anti-TB drugs.
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Affiliation(s)
- Helena Huerga
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Uzma Khan
- Uzma Khan, Palwasha Y Khan: Interactive Research and Development (IRD) Global, Singapore, Singapore
| | - Mathieu Bastard
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Carole D Mitnick
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Nathalie Lachenal
- Nathalie Lachenal, Elna Osso: Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Palwasha Y Khan
- Uzma Khan, Palwasha Y Khan: Interactive Research and Development (IRD) Global, Singapore, Singapore.,Palwasha Y Khan: Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Kwonjune J Seung
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Nara Melikyan
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Saman Ahmed
- Saman Ahmed: Interactive Research and Development (IRD), Karachi, Pakistan
| | - Michael L Rich
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Francis Varaine
- Francis Varaine, Catherine Hewison: Medical Department, Médecins Sans Frontières, Paris, France
| | - Elna Osso
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Nathalie Lachenal, Elna Osso: Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | | | - Naseem Salahuddin
- Naseem Salahuddin: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | - Gocha Salia
- Gocha Salia: Medical Department, Médecins Sans Frontières, Tbilisi, Georgia
| | - Epifanio Sánchez
- Epifanio Sánchez: Hospital Nacional Sergio Bernales Hospital, Lima, Peru
| | - Armine Serobyan
- Armine Serobyan: Medical Department, Médecins Sans Frontières, Yerevan, Armenia
| | | | | | - Dmitry Vetushko
- Dmitry Vetushko: The Republican Scientific and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | | | - David Holtzman
- David Holtzman: Partners In Health, Lesotho, Maseru, Lesotho
| | - Shirajul Islam
- Shirajul Islam, Shahid Mamsa: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | | | | | - Olga Leonovich
- Olga Leonovich: Medical Department, Médecins Sans Frontières, Minsk, Belarus
| | - Shahid Mamsa
- Shirajul Islam, Shahid Mamsa: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | - Mohammad Manzur-Ul-Alam
- Mohammad Manzur-ul-Alam, Shirajul Islam: Interactive Research and Development (IRD), Dhaka, Bangladesh
| | - Zaw Myint
- Zaw Myint: National Tuberculosis Program central, Yangon branch, Myanmar
| | - Shrivani Padayachee
- Shrivani Padayachee: Interactive Research and Development (IRD), Durban, South Africa
| | - Molly F Franke
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Catherine Hewison
- Francis Varaine, Catherine Hewison: Medical Department, Médecins Sans Frontières, Paris, France
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MDR Tuberculosis Treatment. Medicina (B Aires) 2022; 58:medicina58020188. [PMID: 35208510 PMCID: PMC8878254 DOI: 10.3390/medicina58020188] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 11/17/2022] Open
Abstract
Multidrug-resistant (MDR) tuberculosis (TB), resistant to isoniazid and rifampicin, continues to be one of the most important threats to controlling the TB epidemic. Over the last few years, there have been promising pharmacological advances in the paradigm of MDR TB treatment: new and repurposed drugs have shown excellent bactericidal and sterilizing activity against Mycobacterium tuberculosis and several all-oral short regimens to treat MDR TB have shown promising results. The purpose of this comprehensive review is to summarize the most important drugs currently used to treat MDR TB, the recommended regimens to treat MDR TB, and we also summarize new insights into the treatment of patients with MDR TB.
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Hewison C, Khan U, Bastard M, Lachenal N, Coutisson S, Osso E, Ahmed S, Khan P, Franke MF, Rich ML, Varaine F, Melikyan N, Seung KJ, Adenov M, Adnan S, Danielyan N, Islam S, Janmohamed A, Karakozian H, Kamene Kimenye M, Kirakosyan O, Kholikulov B, Krisnanda A, Kumsa A, Leblanc G, Lecca L, Nkuebe M, Mamsa S, Padayachee S, Thit P, Mitnick CD, Huerga H. Safety of Treatment Regimens Containing Bedaquiline and Delamanid in the endTB Cohort. Clin Infect Dis 2022; 75:1006-1013. [PMID: 35028659 PMCID: PMC9522425 DOI: 10.1093/cid/ciac019] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Safety of treatment for multidrug-resistant tuberculosis (MDR/RR-TB) can be an obstacle to treatment completion. Evaluate safety of longer MDR/RR-TB regimens containing bedaquiline and/or delamanid. METHODS Multicentre (16 countries), prospective, observational study reporting incidence and frequency of clinically relevant adverse events of special interest (AESIs) among patients who received MDR/RR-TB treatment containing bedaquiline and/or delamanid. The AESIs were defined a priori as important events caused by bedaquiline, delamanid, linezolid, injectables, and other commonly used drugs. Occurrence of these events was also reported by exposure to the likely causative agent. RESULTS Among 2296 patients, the most common clinically relevant AESIs were peripheral neuropathy (26.4%), electrolyte depletion (26.0%), and hearing loss (13.2%) with an incidence per 1000 person months of treatment, 1000 person-months of treatment 21.5 (95% confidence interval [CI]: 19.8-23.2), 20.7 (95% CI: 19.1-22.4), and 9.7 (95% CI: 8.6-10.8), respectively. QT interval was prolonged in 2.7% or 1.8 (95% CI: 1.4-2.3)/1000 person-months of treatment. Patients receiving injectables (N = 925) and linezolid (N = 1826) were most likely to experience events during exposure. Hearing loss, acute renal failure, or electrolyte depletion occurred in 36.8% or 72.8 (95% CI: 66.0-80.0) times/1000 person-months of injectable drug exposure. Peripheral neuropathy, optic neuritis, and/or myelosuppression occurred in 27.8% or 22.8 (95% CI: 20.9-24.8) times/1000 patient-months of linezolid exposure. CONCLUSIONS AEs often related to linezolid and injectable drugs were more common than those frequently attributed to bedaquiline and delamanid. MDR-TB treatment monitoring and drug durations should reflect expected safety profiles of drug combinations. CLINICAL TRIALS REGISTRATION NCT02754765.
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Affiliation(s)
- Catherine Hewison
- Correspondence: Catherine Hewison, Medical Department, Médecins Sans Frontières, 14-34 avenue Jean Jaurès, 75019, Paris, France () and ()
| | | | | | - Nathalie Lachenal
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Sylvine Coutisson
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Elna Osso
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Saman Ahmed
- Interactive Research and Development, Karachi, Pakistan
| | - Palwasha Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Molly F Franke
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael L Rich
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Nara Melikyan
- Field Epidemiology Department, Epicentre, Paris, France
| | - Kwonjune J Seung
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Malik Adenov
- National Scientific Center of Phthisiopulmonology, MOH RK (NSCP MOH RK), Almaty, Kazakhstan
| | | | | | | | | | - Hayk Karakozian
- Medical Department, Médecins Sans Frontières, Bishkek, Krygystan
| | | | | | | | - Aga Krisnanda
- Aga Krisnanda, Interactive Research and Development, Jakarta, Indonesia
| | | | | | | | | | | | | | - Phone Thit
- Medical Department, Médecins Sans Frontières, Yangon, Myanmar
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Black TA, Buchwald UK. The pipeline of new molecules and regimens against drug-resistant tuberculosis. J Clin Tuberc Other Mycobact Dis 2021; 25:100285. [PMID: 34816020 PMCID: PMC8593651 DOI: 10.1016/j.jctube.2021.100285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The clinical development and regulatory approval of bedaquiline, delamanid and pretomanid over the last decade brought about significant progress in the management of drug-resistant tuberculosis, providing all-oral regimens with favorable safety profiles. The Nix-TB and ZeNix trials of a bedaquiline - pretomanid - linezolid regimen demonstrated for the first time that certain forms of drug-resistant tuberculosis can be cured in the majority of patients within 6 months. Ongoing Phase 3 studies containing these drugs may further advance optimized regimen compositions. Investigational drugs in clinical development that target clinically validated mechanisms, such as second generation oxazolidinones (sutezolid, delpazolid, TBI-223) and diarylquinolines (TBAJ-876 and TBAJ-587) promise improved potency and/or safety compared to the first-in-class drugs. Compounds with novel targets involved in diverse bacterial functions such as cell wall synthesis (DrpE1, MmpL3), electron transport, DNA synthesis (GyrB), cholesterol metabolism and transcriptional regulation of ethionamide bioactivation pathways have advanced to early clinical studies with the potential to enhance antibacterial activity when added to new or established anti-TB drug regimens. Clinical validation of preclinical in vitro and animal model predictions of new anti-TB regimens may further improve the translational value of these models to identify optimal anti-TB therapies.
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Affiliation(s)
- Todd A. Black
- Global Alliance for TB Drug Development, 40 Wall Street, 24th Floor, New York, NY 10005, USA
| | - Ulrike K. Buchwald
- Global Alliance for TB Drug Development, 40 Wall Street, 24th Floor, New York, NY 10005, USA
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Population Pharmacokinetic and Concentration-QTc Analysis of Delamanid in Pediatric Participants with Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2021; 66:e0160821. [PMID: 34843388 PMCID: PMC8846319 DOI: 10.1128/aac.01608-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A population pharmacokinetic analysis of delamanid and its major metabolite DM-6705 was conducted to characterize the pharmacokinetics of delamanid and DM-6705 in pediatric participants with multidrug-resistant tuberculosis (MDR-TB). Data from participants between the ages of 0.67 and 17 years, enrolled in 2 clinical trials, were utilized for the analysis. The final data set contained 634 delamanid and 706 DM-6705 valid plasma concentrations from 37 children. A transit model with three compartments best described the absorption of delamanid. Two-compartment models for each component with linear elimination were selected to characterize the dispositions of delamanid and DM-6705, respectively. The covariates included in the model were body weight on the apparent volume of distribution and apparent clearance (for both delamanid and DM-6705); formulation (dispersible versus film-coated tablet) on the mean absorption time; age, formulation, and dose on the bioavailability of delamanid; and age on the fraction of delamanid metabolized to DM-6705. Based on the simulations, doses for participants within different age/weight groups that result in delamanid exposure comparable to that in adults following the approved adult dose were calculated. By concentration-QTc (QTcB [QT corrected by Bazett’s formula]) analysis, a significant positive correlation was detected with concentrations of DM-6705. However, the model-predicted upper bounds of the 90% confidence intervals of ΔQTc values were <10 ms at the simulated maximum concentration (Cmax) of DM-6705 following the administration of the maximum doses simulated. This suggests that the effect on the QT interval following the proposed dosing is unlikely to be clinically meaningful in children with MDR-TB who receive delamanid.
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Ausi Y, Santoso P, Sunjaya DK, Barliana MI. Between Curing and Torturing: Burden of Adverse Reaction in Drug-Resistant Tuberculosis Therapy. Patient Prefer Adherence 2021; 15:2597-2607. [PMID: 34848950 PMCID: PMC8627322 DOI: 10.2147/ppa.s333111] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/09/2021] [Indexed: 01/07/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) requires prolonged and complex therapy which is associated with several adverse drug reactions (ADR). The burden of ADR can affect the quality of life (QoL) of patients that consists of physical, mental, and social well-being, and influences the beliefs and behaviors of patient related to treatment. This article reviews the burden of ADR and its association with QoL and adherence. We used PubMed to retrieve the relevant original research articles written in English from 2011 to 2021. We combined the following keywords: "tuberculosis," "Drug-resistant tuberculosis," "Side Effect," "Adverse Drug Reactions," "Adverse Event," "Quality of Life," "Adherence," "Non-adherence," "Default," and "Loss to follow-up." Article selection process was unsystematic. We included 12 relevant main articles and summarized into two main topics, namely, 1) ADR and QoL (3 articles), and 2) ADR and therapy adherence (9 articles). The result showed that patients with ADR tend to have low QoL, even in the end of treatment. Although it was torturing, the presence of ADR does not always result in non-adherence. It is probably because the perception about the benefit of the treatment dominates the perceived barrier. In conclusion, burden of ADR generally tends to degrade QoL of patients and potentially influence the adherence. A comprehensive support from family, community, and healthcare provider is required to help patients in coping with the burden of ADR. Nevertheless, the regimen safety and efficacy improvement are highly needed.
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Affiliation(s)
- Yudisia Ausi
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Master Program in Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Prayudi Santoso
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Deni Kurniadi Sunjaya
- Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Melisa Intan Barliana
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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Khoshnood S, Taki E, Sadeghifard N, Kaviar VH, Haddadi MH, Farshadzadeh Z, Kouhsari E, Goudarzi M, Heidary M. Mechanism of Action, Resistance, Synergism, and Clinical Implications of Delamanid Against Multidrug-Resistant Mycobacterium tuberculosis. Front Microbiol 2021; 12:717045. [PMID: 34690963 PMCID: PMC8529252 DOI: 10.3389/fmicb.2021.717045] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/02/2021] [Indexed: 11/21/2022] Open
Abstract
Multidrug-resistant (MDR) isolates of Mycobacterium tuberculosis (MTB) remain a primary global threat to the end of tuberculosis (TB) era. Delamanid (DLM) is a nitro-dihydro-imidazooxazole derivative utilized to treat MDR-TB. DLM has distinct mechanism of action, inhibiting methoxy- and keto-mycolic acid (MA) synthesis through the F420 coenzyme mycobacteria system and generating nitrous oxide. While DLM resistance among MTB strains is uncommon, there are increasing reports in Asia and Europe, and such resistance will prolong the treatment courses of patients infected with MDR-TB. In this review, we address the antimycobacterial properties of DLM, report the global prevalence of DLM resistance, discuss the synergism of DLM with other anti-TB drugs, and evaluate the documented clinical trials to provide new insights into the clinical use of this antibiotic.
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Affiliation(s)
- Saeed Khoshnood
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Elahe Taki
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nourkhoda Sadeghifard
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Vahab Hassan Kaviar
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | | | - Zahra Farshadzadeh
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Microbiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ebrahim Kouhsari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Heidary
- Department of Laboratory Sciences, School of Paramedical Sciences, Sabzevar University of Medical Sciences, Sabzevar, Iran
- Cellular and Molecular Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
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Wang MG, Wu SQ, He JQ. Efficacy of bedaquiline in the treatment of drug-resistant tuberculosis: a systematic review and meta-analysis. BMC Infect Dis 2021; 21:970. [PMID: 34535090 PMCID: PMC8447831 DOI: 10.1186/s12879-021-06666-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background Drug-resistant tuberculosis (DR-TB) remains a major public health concern worldwide. Bedaquiline, a novel diarylquinoline, was added to the WHO-recommended all-oral regimen for patients with multidrug-resistant tuberculosis. We performed a systematic review and meta-analysis to determine the effect of bedaquiline on tuberculosis treatment outcomes. Methods We searched the PubMed, Web of Science and EMBASE databases for relevant studies published up to March 12, 2021. We included studies in which some participants received bedaquiline and others did not. Stata version 16.0 (Stata Corp., College Station, Texas, USA) was used to analyze the results of the meta-analysis. Risk ratios (RRs) with 95% confidence intervals (95% CIs) were calculated to evaluate the effect of bedaquiline on drug-resistant tuberculosis. Between-study heterogeneity was examined by the I-squared test. Randomized controlled trials were assessed for quality using the Jadad scale, and cohort studies were assessed using the Newcastle–Ottawa scale. Results Eight studies, including 2 randomized controlled trials and 6 cohort studies involving a total of 21,836 subjects, were included. When compared with the control, bedaquiline treatment was associated with higher rates of culture conversion (risk ratio (RR):1.272 (1.165–1.389), P < 0.001). We found substantial evidence of a significant reduction in all-cause death (RR: 0.529 (0.454–0.616), P < 0.001)) in the bedaquiline treatment group. There was no significant reduction in treatment success (RR = 0.980 (0.948–1.013, P = 0.234)). Conclusions This study demonstrated that compared with patients who do not receive bedaquiline, this drug has the potential to achieve a higher culture conversion rate and a lower mortality risk among drug-resistant tuberculosis cases. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06666-8.
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Affiliation(s)
- Ming-Gui Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, Sichuan, People's Republic of China
| | - Shou-Quan Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, Sichuan, People's Republic of China
| | - Jian-Qing He
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, Sichuan, People's Republic of China.
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Kang Y, Mok J. Treatment Outcomes of Patients with Multidrug-resistant Tuberculosis: Concern to Bedaquiline - Authors' reply. Tuberc Respir Dis (Seoul) 2021; 85:98-99. [PMID: 34510868 PMCID: PMC8743637 DOI: 10.4046/trd.2021.0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 09/12/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yewon Kang
- Department of Internal Medicine, Dongkang Medical Center, Ulsan, Republic of Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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