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Holger DJ, Althubyani A, Morrisette T, Rebold N, Tailor M. Updates in pulmonary drug-resistant tuberculosis pharmacotherapy: A focus on BPaL and BPaLM. Pharmacotherapy 2024; 44:268-282. [PMID: 38270468 DOI: 10.1002/phar.2909] [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: 08/08/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 01/26/2024]
Abstract
Drug-resistant tuberculosis (TB) is a major public health concern and contributes to high morbidity and mortality. New evidence supports the use of shorter duration, all-oral regimens, which represent an encouraging treatment strategy for drug-resistant TB. As a result, the landscape of drug-resistant TB pharmacotherapy has drastically evolved regarding treatment principles and preferred agents. This narrative review focuses on the key updates of drug-resistant TB treatment, including the use of short-duration all-oral regimens, while calling attention to current gaps in knowledge that may be addressed in future observational studies.
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Affiliation(s)
- Dana J Holger
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Department of Pharmacy Services, Memorial Hospital West, Pembroke Pines, Florida, USA
| | - Ali Althubyani
- Department of Pharmacy Services, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Taylor Morrisette
- Department of Clinical Pharmacy & Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA
- Department of Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Nicholas Rebold
- Department of Clinical & Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Marylee Tailor
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
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Mehta K, Guo T, van der Graaf PH, van Hasselt JGC. Model-based dose optimization framework for bedaquiline, pretomanid and linezolid for the treatment of drug-resistant tuberculosis. Br J Clin Pharmacol 2024; 90:463-474. [PMID: 37817504 DOI: 10.1111/bcp.15925] [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: 06/22/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/12/2023] Open
Abstract
AIMS Bedaquiline, pretomanid and linezolid (BPaL) combination treatment against Mycobacterium tuberculosis is promising, yet safety and adherence concerns exist that motivate exploration of alternative dosing regimens. We developed a mechanistic modelling framework to compare the efficacy of the current and alternative BPaL treatment strategies. METHODS Pharmacodynamic models for each drug in the BPaL combination treatment were developed using in vitro time-kill data. These models were combined with pharmacokinetic models, incorporating body weight, lesion volume, site-of-action distribution, bacterial susceptibility and pharmacodynamic interactions to assemble the framework. The model was qualified by comparing the simulations against the observed clinical data. Simulations were performed evaluating bedaquiline and linezolid approved (bedaquiline 400 mg once daily [QD] for 14 days followed by 200 mg three times a week, linezolid 1200 mg QD) and alternative dosing regimens (bedaquiline 200 mg QD, linezolid 600 mg QD). RESULTS The framework adequately described the observed antibacterial activity data in patients following monotherapy for each drug and approved BPaL dosing. The simulations suggested a minor difference in median time to colony forming unit (CFU)-clearance state with the bedaquiline alternative compared to the approved dosing and the linezolid alternative compared to the approved dosing. Median time to non-replicating-clearance state was predicted to be 15 days from the CFU-clearance state. CONCLUSIONS The model-based simulations suggested that comparable efficacy can be achieved using alternative bedaquiline and linezolid dosing, which may improve safety and adherence in drug-resistant tuberculosis patients. The framework can be utilized to evaluate treatment optimization approaches, including dosing regimen and duration of treatment predictions to eradicate both replicating- and non-replicating bacteria from lung and lesions.
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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
| | - J G Coen van Hasselt
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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Sauer SM, Mitnick CD, Khan U, Hewison C, Bastard M, Holtzman D, Law S, Khan M, Padayachee S, Ahmed S, Isani AK, Krisnanda A, Vilbrun SC, Bektasov S, Kumsa A, Docteur W, Tintaya K, McNicol M, Atshemyan H, Voynilo T, Thwe TT, Seung K, Rich M, Huerga H, Khan P, Franke M. Estimating Post-treatment Recurrence After Multidrug-Resistant Tuberculosis Treatment Among Patients With and Without Human Immunodeficiency Virus: The Impact of Assumptions About Death and Missing Follow-up. Clin Infect Dis 2024; 78:164-171. [PMID: 37773767 PMCID: PMC10810712 DOI: 10.1093/cid/ciad589] [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: 05/22/2023] [Revised: 08/22/2023] [Accepted: 09/26/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Quantification of recurrence risk following successful treatment is crucial to evaluating regimens for multidrug- or rifampicin-resistant (MDR/RR) tuberculosis (TB). However, such analyses are complicated when some patients die or become lost during post-treatment follow-up. METHODS We analyzed data on 1991 patients who successfully completed a longer MDR/RR-TB regimen containing bedaquiline and/or delamanid between 2015 and 2018 in 16 countries. Using 5 approaches for handling post-treatment deaths, we estimated 6-month post-treatment TB recurrence risk overall and by HIV status. We used inverse-probability weighting to account for patients with missing follow-up and investigated the impact of potential bias from excluding these patients without applying inverse-probability weights. RESULTS The estimated TB recurrence risk was 7.4/1000 (95% credible interval: 3.3-12.8) when deaths were handled as non-recurrences and 7.6/1000 (3.3-13.0) when deaths were censored and inverse-probability weights were applied to account for the excluded deaths. The estimated risks of composite recurrence outcomes were 25.5 (15.3-38.1), 11.7 (6.4-18.2), and 8.6 (4.1-14.4) per 1000 for recurrence or (1) any death, (2) death with unknown or TB-related cause, or (3) TB-related death, respectively. Corresponding relative risks for HIV status varied in direction and magnitude. Exclusion of patients with missing follow-up without inverse-probability weighting had a small impact on estimates. CONCLUSIONS The estimated 6-month TB recurrence risk was low, and the association with HIV status was inconclusive due to few recurrence events. Estimation of post-treatment recurrence will be enhanced by explicit assumptions about deaths and appropriate adjustment for missing follow-up data.
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Affiliation(s)
- Sara M Sauer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Uzma Khan
- Interactive Research and Development (IRD) Global, Singapore, Singapore
| | | | | | | | - Stephanie Law
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Afshan K Isani
- Centers for Disease Control and Prevention, Directorate General Health Services, Sindh, Pakistan
| | | | - Stalz Charles Vilbrun
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | | | | | | | | | | | | | | | - Kwonjune Seung
- Partners in Health, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Rich
- Partners in Health, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Palwasha Khan
- Interactive Research and Development (IRD) Global, Singapore, Singapore
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Molly Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Ke H, Gui X, Sun W, Zhang S, Yang Y, Zhang Z, Fan L. The Safety and Efficacy of Prolonged Use of Bedaquiline for the Treatment of Patients with Pulmonary Multi-Drug Resistant/Rifampin-Resistant Tuberculosis: A Prospective, Cohort Study in China. Infect Drug Resist 2023; 16:5055-5064. [PMID: 37576523 PMCID: PMC10417604 DOI: 10.2147/idr.s419996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To evaluate the safety, tolerability, and efficacy of prolonged bedaquiline (Bdq) treatment in patients with multi-drug/rifampin-resistant tuberculosis (MDR/RR-TB). Methods This prospective cohort study was performed from August 2018 to August 2021. Patients diagnosed with MDR/RR-TB who met the inclusion criteria were prospectively included. Patients were treated with individual regimens of 18-20 months containing Bdq for six months or a prolonged course of nine or 12 months according to treatment demands, and the efficacy and safety with a different course of Bdq-containing regimens were compared and evaluated. Results A total of 159 MDR/RR-TB patients were included in the study, including 96 cases with six months of Bdq, 50 cases with nine months of Bdq, and 13 patients with 12 months of Bdq. The treatment success rates were 89.6%, 90%, and 84.6% in Bdq at six months, nine months, and 12 months, respectively, which were not statistically different (P = 0.85). The main adverse events (AEs) were anemia, thrombocytopenia, and liver dysfunction in all patients, with no significant difference among the three groups. Patients who had fewer drugs chosen, disseminated lesions or lesions that were slowly absorbed, and severe cavities were the common reasons for prolonged use of Bdq. Conclusion Prolonged course use of Bdq from six months to 12 months clinically proved to be safe and efficient, and patients with severe or disseminated lesions had the chance to prolong the use of Bdq for more than six months to achieve optimal treatment outcomes.
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Affiliation(s)
- Hui Ke
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
| | - Xuwei Gui
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
| | - Wenwen Sun
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
| | - Shaojun Zhang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
| | - Yan Yang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
| | - Zhemin Zhang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
| | - Lin Fan
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai, People’s Republic of China
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Kim JH, Lee H, Oh IS, Jeong HE, Bea S, Jang SH, Son H, Shin JY. Comparative safety of bedaquiline and delamanid in patients with multidrug resistant tuberculosis: A nationwide retrospective cohort study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:842-852. [PMID: 37202241 DOI: 10.1016/j.jmii.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/27/2023] [Accepted: 04/20/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND/PURPOSE(S) Bedaquiline and delamanid were recently approved for multidrug resistant tuberculosis (MDR-TB). Bedaquiline carries a black box warning of increased risk of death compared to the placebo arm, and there is a need to establish the risks of QT prolongation and hepatotoxicity for bedaquiline and delamanid. METHODS We retrospectively analyzed data of MDR-TB patients retrieved from the South Korea national health insurance system database (2014-2020) to assess the risks of all-cause death, long QT-related cardiac event, and acute liver injury associated with bedaquiline or delamanid, compared with conventional regimen. Cox proportional hazards models were used to estimate hazard ratios (HR) with 95% confidence intervals (CI). Stabilized inverse probability of treatment weighting based on propensity score was used to balance characteristics between the treatment groups. RESULTS Of 1998 patients, 315 (15.8%) and 292 (14.6%) received bedaquiline and delamanid, respectively. Compared with conventional regimen, bedaquiline and delamanid did not increase risk of all-cause death at 24-month (HR 0.73 [95% CI, 0.42-1.27] and 0.89 [0.50-1.60], respectively). Bedaquiline-containing regimen increased risk of acute liver injury (1.76 [1.31-2.36]), while delamanid-containing regimen increased risk of long QT-related cardiac events (2.38 [1.05-3.57]) within 6 months of treatment. CONCLUSION This study adds to the emerging evidence refuting the higher mortality rate observed in the bedaquiline trial population. Association between bedaquiline and acute liver injury needs careful interpretation considering for other background hepatotoxic anti-TB drugs. Our finding on delamanid and long QT-related cardiac events suggest careful risk-benefit assessment in patients with pre-existing cardiovascular disease.
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Affiliation(s)
- Ju Hwan Kim
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea
| | - In-Sun Oh
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea
| | - Sungho Bea
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Seung Hun Jang
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Hyunjin Son
- Department of Preventive Medicine, College of Medicine, Dong-A University, Busan, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea; Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea.
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Sauer SM, Mitnick CD, Khan U, Hewison C, Bastard M, Holtzman D, Law S, Khan M, Padayachee S, Ahmed S, Isani AK, Krisnanda A, Vilbrun SC, Bektasov S, Kumsa A, Docteur W, Tintaya K, McNicol M, Atshemyan H, Voynilo T, Thwe TT, Seung K, Rich M, Huerga H, Khan P, Franke M. Estimating post-treatment recurrence after multidrug-resistant tuberculosis treatment among patients with and without HIV: the impact of assumptions about death and missing follow-up. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.24.23290472. [PMID: 37398252 PMCID: PMC10312883 DOI: 10.1101/2023.05.24.23290472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Background Quantification of recurrence risk following successful treatment is crucial to evaluating regimens for multidrug- or rifampicin-resistant (MDR/RR) tuberculosis (TB). However, such analyses are complicated when some patients die or become lost during post-treatment-follow-up. Methods We analyzed data on 1,991 patients who successfully completed a longer MDR/RR-TB regimen containing bedaquiline and/or delamanid between 2015 and 2018 in 16 countries. Using five approaches for handling post-treatment deaths, we estimated the six-month post-treatment TB recurrence risk overall, and by HIV status. We used inverse-probability-weighting to account for patients with missing follow-up and investigated the impact of potential bias from excluding these patients without applying inverse-probability weights. Results The estimated TB recurrence risk was 6.6 per 1000 (95% confidence interval (CI):3.2,11.2) when deaths were handled as non-recurrences, and 6.7 per 1000 (95% CI:2.8,12.2) when deaths were censored and inverse-probability weights were applied to account for the excluded deaths. The estimated risk of composite recurrence outcomes were 24.2 (95% CI:14.1,37.0), 10.5 (95% CI:5.6,16.6), and 7.8 (95% CI:3.9,13.2) per 1000 for recurrence or 1) any death, 2) death with unknown or TB-related cause, 3) TB-related death, respectively. Corresponding relative risks for HIV status varied in direction and magnitude. Exclusion of patients with missing follow-up without inverse-probability-weighting had a small but apparent impact on estimates. Conclusion The estimated six-month TB recurrence risk was low, and the association with HIV status was inconclusive due to few recurrence events. Estimation of post-treatment recurrence will be enhanced by explicit assumptions about deaths and appropriate adjustment for missing follow-up data.
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