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Sarkar M, Sarkar J. Therapeutic drug monitoring in tuberculosis. Eur J Clin Pharmacol 2024; 80:1659-1684. [PMID: 39240337 DOI: 10.1007/s00228-024-03749-8] [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: 05/23/2024] [Accepted: 08/26/2024] [Indexed: 09/07/2024]
Abstract
PURPOSE Therapeutic drug monitoring (TDM) is a standard clinical procedure that uses the pharmacokinetic and pharmacodynamic parameters of the drug in the body to determine the optimal dose. The pharmacokinetic variability of the drug(s) is a significant contributor to poor treatment outcomes, including the development of acquired drug resistance. TDM aids in dose optimization and improves outcomes while lessening drug toxicity. TDM is used to manage patients with tuberculosis (TB) who exhibit a slow response to therapy, despite good compliance and drug-susceptible organisms. Additional indications include patients at risk of malabsorption or delayed absorption of TB drugs and patients with drug-drug interaction and drug toxicity, which confirm compliance with therapy. TDM usually requires two blood samples: the 2 h and the 6 h post-dose. This narrative review will discuss the pharmacokinetics and pharmacodynamics of TB drugs, determinants of poor response to therapy, indications of TDM, methods of performing TDM, and its interpretations. METHODS This is a narrative review. We searched PubMed, Embase, and the CINAHL from inception to April 2024. We used the following search terms: tuberculosis, therapeutic drug monitoring, anti-TB drugs, pharmacokinetics, pharmacodynamics, limited sample strategies, diabetes and TB, HIV and TB, and multidrug-resistant TB. All types of articles were selected. RESULTS TDM is beneficial in managing TB, especially in patients with slow responses, drug-resistance TB, recurrent TB, and comorbidities such as diabetes mellitus and human immunodeficiency virus infection. CONCLUSION TDM is beneficial for improving outcomes, reducing the risk of acquired drug resistance, and avoiding side effects.
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Affiliation(s)
- M Sarkar
- Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, 171001, Himachal Pradesh, India.
| | - J Sarkar
- MRes Neuroscience, University of Leeds, Leeds, UK
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Gafar F, Yunivita V, Fregonese F, Apriani L, Aarnoutse RE, Ruslami R, Menzies D. Pharmacokinetics of standard versus high-dose rifampin for tuberculosis preventive treatment: A sub-study of the 2R 2 randomized controlled trial. Int J Antimicrob Agents 2024; 64:107197. [PMID: 38750674 DOI: 10.1016/j.ijantimicag.2024.107197] [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: 11/23/2023] [Revised: 03/18/2024] [Accepted: 05/06/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Pharmacokinetic data of rifampin, when used for tuberculosis preventive treatment (TPT) are not available. We aimed to describe the pharmacokinetics of rifampin used for TPT, at standard and higher doses, and to assess predictors of rifampin exposure. METHODS A pharmacokinetic sub-study was performed in Bandung, Indonesia among participants in the 2R2 randomized trial, which compared TPT regimens of 2 months of high-dose rifampin at 20 mg/kg/day (2R20) and 30 mg/kg/day (2R30), with 4 months of standard-dose rifampin at 10 mg/kg/day (4R10) in adolescents and adults. Intensive pharmacokinetic sampling was performed after 2-8 weeks of treatment. Pharmacokinetic parameters were assessed non-compartmentally. Total exposure (AUC0-24) and peak concentration (Cmax) between arms were compared using one-way ANOVA and Tukey's post-hoc tests. Multivariable linear regression analyses were used to assess predictors of AUC0-24 and Cmax. RESULTS We enrolled 51 participants in this study. In the 4R10, 2R20, and 2R30 arms, the geometric mean AUC0-24 was 68.0, 186.8, and 289.9 h⋅mg/L, and Cmax was 18.4, 36.7, and 54.4 mg/L, respectively; high interindividual variabilities were observed. Compared with the 4R10 arm, AUC0-24 and Cmax were significantly higher in the 2R20 and 2R30 arms (P < 0.001). Drug doses, body weight, and female sex were predictors of higher rifampin AUC0-24 and Cmax (P < 0.05). AUC0-24 and Cmax values were much higher than those previously reported in persons with TB disease. CONCLUSIONS Doubling and tripling the rifampin dose led to three- and four-fold higher exposure compared to standard dose. Pharmacokinetic/pharmacodynamic modelling and simulations are warranted to support trials of shortening the duration of TPT regimens with high-dose rifampin.
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Affiliation(s)
- Fajri Gafar
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; McGill International TB Centre, McGill University, Montreal, Quebec, Canada; Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Vycke Yunivita
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; TB Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Federica Fregonese
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Lika Apriani
- TB Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia; Division of Epidemiology and Biostatistics, Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud university medical center, Nijmegen, The Netherlands
| | - Rovina Ruslami
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada; Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; TB Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; McGill International TB Centre, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada.
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Hou W, Huo KG, Guo X, Xu M, Yang Y, Shi Z, Xu W, Tu J, Gao T, Ma Z, Han S. KLF15-Cyp3a11 Axis Regulates Rifampicin-Induced Liver Injury. Drug Metab Dispos 2024; 52:606-613. [PMID: 38670799 DOI: 10.1124/dmd.123.001617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/29/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Rifampicin (RFP) has demonstrated potent antibacterial effects in the treatment of pulmonary tuberculosis. However, the serious adverse effects on the liver intensively limit the clinical usage of the drug. Deacetylation greatly reduces the toxicity of RFP but also retains its curative activity. Here, we found that Krüppel-like factor 15 (KLF15) repressed the expression of the major RFP detoxification enzyme Cyp3a11 in mice via both direct and indirect mechanisms. Knockout of hepatocyte KLF15 induced the expression of Cyp3a11 and robustly attenuated the hepatotoxicity of RFP in mice. In contrast, overexpression of hepatic KLF15 exacerbated RFP-induced liver injury as well as mortality. More importantly, the suppression of hepatic KLF15 expression strikingly restored liver functions in mice even after being pretreated with overdosed RFP. Therefore, this study identified the KLF15-Cyp3a11 axis as a novel regulatory pathway that may play an essential role in the detoxification of RFP and associated liver injury. SIGNIFICANCE STATEMENT: Rifampicin has demonstrated antibacterial effects in the treatment of pulmonary tuberculosis. However, the serious adverse effects on the liver limit the clinical usage of the drug. Permanent depletion and transient inhibition of hepatic KLF15 expression significantly induced the expression of Cyp3a11 and robustly attenuated mouse hepatotoxicity induced by RFP. Overall, our studies show the KLF15-Cyp3a11 axis was identified as a novel regulatory pathway that may play an essential role in the detoxification of RFP and associated liver injury.
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Affiliation(s)
- Wanqing Hou
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Ku-Geng Huo
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Xiaohua Guo
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Mengtong Xu
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Yongting Yang
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Zhuangqi Shi
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Weixiong Xu
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Jinqi Tu
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Tangxin Gao
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Zhenghai Ma
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
| | - Shuxin Han
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China (W.H., X.G.); Cyagen Biosciences (Guangzhou) Inc. Guangzhou, Guangdong, China (K.-G.H.); Xinjiang Key Laboratory of Biological Resources and Genetic Engineering, College of Life Science and Technology, Xinjiang University, Urumqi, China (M.X., Y.Y., Z.S., J.T., Z.M., S.H.); Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio (W.X.); and Lantu Biopharma, Guangzhou, China (T.G.)
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Ngo HX, Xu AY, Velásquez GE, Zhang N, Chang VK, Kurbatova EV, Whitworth WC, Sizemore E, Bryant K, Carr W, Weiner M, Dooley KE, Engle M, Dorman SE, Nahid P, Swindells S, Chaisson RE, Nsubuga P, Lourens M, Dawson R, Savic RM. Pharmacokinetic-Pharmacodynamic Evidence From a Phase 3 Trial to Support Flat-Dosing of Rifampicin for Tuberculosis. Clin Infect Dis 2024; 78:1680-1689. [PMID: 38462673 PMCID: PMC11175687 DOI: 10.1093/cid/ciae119] [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: 11/09/2023] [Revised: 02/23/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND The optimal dosing strategy for rifampicin in treating drug-susceptible tuberculosis (TB) is still highly debated. In the phase 3 clinical trial Study 31/ACTG 5349 (NCT02410772), all participants in the control regimen arm received 600 mg rifampicin daily as a flat dose. Here, we evaluated relationships between rifampicin exposure and efficacy and safety outcomes. METHODS We analyzed rifampicin concentration time profiles using population nonlinear mixed-effects models. We compared simulated rifampicin exposure from flat- and weight-banded dosing. We evaluated the effect of rifampicin exposure on stable culture conversion at 6 months; TB-related unfavorable outcomes at 9, 12, and 18 months using Cox proportional hazard models; and all trial-defined safety outcomes using logistic regression. RESULTS Our model-derived rifampicin exposure ranged from 4.57 mg · h/L to 140.0 mg · h/L with a median of 41.8 mg · h/L. Pharmacokinetic simulations demonstrated that flat-dosed rifampicin provided exposure coverage similar to the weight-banded dose. Exposure-efficacy analysis (n = 680) showed that participants with rifampicin exposure below the median experienced similar hazards of stable culture conversion and TB-related unfavorable outcomes compared with those with exposure above the median. Exposure-safety analysis (n = 722) showed that increased rifampicin exposure was not associated with increased grade 3 or higher adverse events or serious adverse events. CONCLUSIONS Flat-dosing of rifampicin at 600 mg daily may be a reasonable alternative to the incumbent weight-banded dosing strategy for the standard-of-care 6-month regimen. Future research should assess the optimal dosing strategy for rifampicin, at doses higher than the current recommendation.
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Affiliation(s)
- Huy X Ngo
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Ava Y Xu
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, California, USA
| | - Gustavo E Velásquez
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nan Zhang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Vincent K Chang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Erin Sizemore
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kia Bryant
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wendy Carr
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Marc Weiner
- University of Texas Health Science Center at San Antonio and the South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Kelly E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Engle
- University of Texas Health Science Center at San Antonio and the South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Susan E Dorman
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Payam Nahid
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Pheona Nsubuga
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Madeleine Lourens
- TASK Applied Science CRS, Brooklyn Chest Hospital, Bellville, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, California, USA
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Ruslami R, Fregonese F, Apriani L, Barss L, Bedingfield N, Chiang V, Cook VJ, Fisher D, Flores E, Fox GJ, Johnston J, Lim RK, Long R, Paulsen C, Nguyen TA, Nhung NV, Gibson D, Valiquette C, Benedetti A, Menzies D. High-dose, short-duration versus standard rifampicin for tuberculosis preventive treatment: a partially blinded, three-arm, non-inferiority, randomised, controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:433-443. [PMID: 38552659 DOI: 10.1016/s2213-2600(24)00076-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Tuberculosis preventive treatment (TPT) is a key component of tuberculosis elimination. To improve completion and reduce the burden for people and health systems, short, safe, and effective TPT regimens are needed. We aimed to compare safety and treatment completion of various doses and durations of rifampicin in people who were recommended to receive TPT. METHODS This partially blinded, parallel-arm, non-inferiority, randomised, controlled, phase 2b trial was done at seven university-affiliated clinics in Canada, Indonesia, and Viet Nam. Participants aged 10 years or older were included if they had an indication for TPT according to WHO guidelines for Indonesia and Viet Nam, or Canadian guidelines for Canadian sites, and a positive tuberculin skin test or interferon-γ release assay. Participants were randomly assigned (1:1:1) to receive oral rifampicin at 10 mg/kg once daily for 4 months (standard-dose group), 20 mg/kg daily for 2 months (20 mg/kg group), or 30 mg/kg daily for 2 months (30 mg/kg group). The randomisation sequence was computer generated with blocks of variable size (three, six, and nine) and stratified by country for Indonesia and Viet Nam, and by city within Canada. Participants and investigators were masked to dose in high-dose groups, but unmasked to duration in all groups. The two co-primary outcomes were safety (in the safety population, in which participants received at least one dose of the study drug) and treatment completion (in the modified intention-to-treat [mITT] population, excluding those ineligible after randomisation). Protocol-defined adverse events were defined as grade 3 or worse, or rash or allergy of any grade, judged by an independent and masked panel as possibly or probably related to the study. A margin of 4% was used to assess non-inferiority. This study is registered with ClinicalTrials.gov, NCT03988933 (active). FINDINGS Between Sept 1, 2019, and Sept 30, 2022, 1692 people were assessed for eligibility, 1376 were randomly assigned, and eight were excluded after randomisation. 1368 participants were included in the mITT population (454 in the standard group, 461 in the 20 mg/kg group, and 453 in the 30 mg/kg group). 589 (43%) participants were male and 779 (57%) were female. 372 (82%) in the standard-dose group, 329 (71%) in the 20 mg/kg group, and 293 (65%) in the 30 mg/kg group completed treatment. No participants in the standard-dose group, one (<1%) of 441 participants in the 20 mg/kg group, and four (1%) of 423 in the 30 mg/kg group developed grade 3 hepatotoxicity. Risk of protocol-defined adverse events was higher in the 30 mg/kg group than in the standard-dose group (adjusted risk difference 4·6% [95% CI 1·8 to 7·4]) or the 20 mg/kg group (5·1% [2·3 to 7·8]). There was no difference in the risk of adverse events between the 20 mg/kg and standard-dose groups (-0·5% [95% CI -2·4 to 1·5]; non-inferiority met). Completion was lower in the 20 mg/kg group (-7·8% [95% CI -13·6 to -2·0]) and the 30 mg/kg group (-15·4% [-21·4 to -9·4]) than in the standard-dose group. INTERPRETATION In this trial, 2 months of 30 mg/kg daily rifampicin had significantly worse safety and completion than 4 months of 10 mg/kg daily and 2 months of 20 mg/kg daily (the latter, a fully blinded comparison); we do not consider 30 mg/kg to be a good option for TPT. Rifampicin at 20 mg/kg daily for 2 months was as safe as standard treatment, but with lower completion. This difference remains unexplained. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Rovina Ruslami
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Federica Fregonese
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Lika Apriani
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Leila Barss
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nancy Bedingfield
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Victor Chiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Victoria J Cook
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Dina Fisher
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eri Flores
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Greg J Fox
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - James Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Rachel K Lim
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Richard Long
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Catherine Paulsen
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Thu Anh Nguyen
- Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Nguyen Viet Nhung
- National Lung Hospital, VNU Ha Noi, Viet Nam; University of Medicine and Pharmacy, VNU Ha Noi, Viet Nam
| | - Diana Gibson
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Chantal Valiquette
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Andrea Benedetti
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Dick Menzies
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada.
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6
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Lehmann A, Geburek I, Hessel-Pras S, Enge AM, Mielke H, Müller-Graf C, Kloft C, Hethey C. PBTK model-based analysis of CYP3A4 induction and the toxicokinetics of the pyrrolizidine alkaloid retrorsine in man. Arch Toxicol 2024; 98:1757-1769. [PMID: 38528153 DOI: 10.1007/s00204-024-03698-2] [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: 12/13/2023] [Accepted: 01/31/2024] [Indexed: 03/27/2024]
Abstract
Cytochrome P450 (CYP)3A4 induction by drugs and pesticides plays a critical role in the enhancement of pyrrolizidine alkaloid (PA) toxicity as it leads to increased formation of hepatotoxic dehydro-PA metabolites. Addressing the need for a quantitative analysis of this interaction, we developed a physiologically-based toxicokinetic (PBTK) model. Specifically, the model describes the impact of the well-characterized CYP3A4 inducer rifampicin on the kinetics of retrorsine, which is a prototypic PA and contaminant in herbal teas. Based on consumption data, the kinetics after daily intake of retrorsine were simulated with concomitant rifampicin treatment. Strongest impact on retrorsine kinetics (plasma AUC24 and C max reduced to 67% and 74% compared to the rifampicin-free reference) was predicted directly after withdrawal of rifampicin. At this time point, the competitive inhibitory effect of rifampicin stopped, while CYP3A4 induction was still near its maximum. Due to the impacted metabolism kinetics, the cumulative formation of intestinal retrorsine CYP3A4 metabolites increased to 254% (from 10 to 25 nmol), while the cumulative formation of hepatic CYP3A4 metabolites was not affected (57 nmol). Return to baseline PA toxicokinetics was predicted 14 days after stop of a 14-day rifampicin treatment. In conclusion, the PBTK model showed to be a promising tool to assess the dynamic interplay of enzyme induction and toxification pathways.
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Affiliation(s)
- Anja Lehmann
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Ina Geburek
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Stefanie Hessel-Pras
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Anne-Margarethe Enge
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Hans Mielke
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany.
| | - Christine Müller-Graf
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Christoph Hethey
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
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Zhang Y, Wu W, Li Q, Zhou P, Wen K, Shen J, Wang Z. The hapten rigidity improves antibody performances in immunoassay for rifamycins: Immunovalidation and molecular mechanism. JOURNAL OF HAZARDOUS MATERIALS 2024; 469:133977. [PMID: 38492395 DOI: 10.1016/j.jhazmat.2024.133977] [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: 12/04/2023] [Revised: 02/24/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
The immunogenicity of haptens determines the performance of the resultant antibody for small molecules. Rigidity is one of the basic physicochemical properties of haptens. However, few studies have investigated the effect of hapten rigidity on the strength of an immune response and overall antibody performance. Herein, we introduce three molecular descriptors that quantify hapten rigidity. By using of these descriptors, four rifamycin haptens with varied rigidity were designed. The structural and physicochemical feasibility of the designed haptens was then assessed by computational chemistry. Immunization demonstrated that the strength of induced immune responses, i.e., the titer and affinity of antiserum, was significantly increased with increased rigidity of haptens. Furthermore, molecular dynamic simulations demonstrated conformation constraint of rigid haptens contributed to the initial binding and activation of naïve B cells. Finally, a highly sensitive indirect competitive enzyme-linked immunosorbent assay was developed for detection of rifaximin, with an IC50 of 1.1 μg/L in buffer and a limit of detection of 0.2-11.3 μg/L in raw milk, river water, and soil samples. This work provides new insights into the effect of hapten rigidity on immunogenicity and offers new hapten design strategies for antibody discovery and vaccine development of small molecules.
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Affiliation(s)
- Yingjie Zhang
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China
| | - Weilin Wu
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China
| | - Qing Li
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China
| | - Penghui Zhou
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China
| | - Kai Wen
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China
| | - Jianzhong Shen
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China
| | - Zhanhui Wang
- National Key Laboratory of Veterinary Public Health and Safety, Beijing Key Laboratory of Detection Technology for Animal-Derived Food, College of Veterinary Medicine, China Agricultural University, 100193 Beijing, People's Republic of China.
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Sáez-López E, Millán-Placer AC, Lucía A, Ramón-García S. Amoxicillin/clavulanate in combination with rifampicin/clarithromycin is bactericidal against Mycobacterium ulcerans. PLoS Negl Trop Dis 2024; 18:e0011867. [PMID: 38573915 PMCID: PMC10994486 DOI: 10.1371/journal.pntd.0011867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/07/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Buruli ulcer (BU) is a skin neglected tropical disease (NTD) caused by Mycobacterium ulcerans. WHO-recommended treatment requires 8-weeks of daily rifampicin (RIF) and clarithromycin (CLA) with wound care. Treatment compliance may be challenging due to socioeconomic determinants. Previous minimum Inhibitory Concentration and checkerboard assays showed that amoxicillin/clavulanate (AMX/CLV) combined with RIF+CLA were synergistic against M. ulcerans. However, in vitro time kill assays (TKA) are a better approach to understand the antimicrobial activity of a drug over time. Colony forming units (CFU) enumeration is the in vitro reference method to measure bacterial load, although this is a time-consuming method due to the slow growth of M. ulcerans. The aim of this study was to assess the in vitro activity of RIF, CLA and AMX/CLV combinations against M. ulcerans clinical isolates by TKA, while comparing four methodologies: CFU enumeration, luminescence by relative light unit (RLU) and optical density (at 600 nm) measurements, and 16S rRNA/IS2404 genes quantification. METHODOLOGY/PRINCIPAL FINDINGS TKA of RIF, CLA and AMX/CLV alone and in combination were performed against different M. ulcerans clinical isolates. Bacterial loads were quantified with different methodologies after 1, 3, 7, 10, 14, 21 and 28 days of treatment. RIF+AMX/CLV and the triple RIF+CLA+AMX/CLV combinations were bactericidal and more effective in vitro than the currently used RIF+CLA combination to treat BU. All methodologies except IS2404 quantitative PCR provided similar results with a good correlation with CFU enumeration. Measuring luminescence (RLU) was the most cost-effective methodology to quantify M. ulcerans bacterial loads in in vitro TKA. CONCLUSIONS/SIGNIFICANCE Our study suggests that alternative and faster TKA methodologies can be used in BU research instead of the cumbersome CFU quantification method. These results provide an in vitro microbiological support to of the BLMs4BU clinical trial (NCT05169554, PACTR202209521256638) to shorten BU treatment.
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Affiliation(s)
- Emma Sáez-López
- Department of Microbiology, Paediatrics, Radiology and Public Health, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
- Spanish Network for Research on Respiratory Diseases (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Ana C. Millán-Placer
- Department of Microbiology, Paediatrics, Radiology and Public Health, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
- Spanish Network for Research on Respiratory Diseases (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Ainhoa Lucía
- Department of Microbiology, Paediatrics, Radiology and Public Health, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
- Spanish Network for Research on Respiratory Diseases (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Santiago Ramón-García
- Department of Microbiology, Paediatrics, Radiology and Public Health, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
- Spanish Network for Research on Respiratory Diseases (CIBERES), Carlos III Health Institute, Madrid, Spain
- Research & Development Agency of Aragón (ARAID) Foundation, Zaragoza, Spain
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9
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Asif M, Qusty NF, Alghamdi S. An Overview of Various Rifampicin Analogs against Mycobacterium tuberculosis and their Drug Interactions. Med Chem 2024; 20:268-292. [PMID: 37855280 DOI: 10.2174/0115734064260853230926080134] [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: 06/10/2023] [Revised: 07/14/2023] [Accepted: 08/12/2023] [Indexed: 10/20/2023]
Abstract
The success of the TB control program is hampered by the major issue of drug-resistant tuberculosis (DR-TB). The situation has undoubtedly been made more difficult by the widespread and multidrug-resistant (XDR) strains of TB. The modification of existing anti-TB medications to produce derivatives that can function on resistant TB bacilli is one of the potential techniques to overcome drug resistance affordably and straightforwardly. In comparison to novel pharmaceuticals for drug research and progress, these may have a better half-life and greater bioavailability, be more efficient, and serve as inexpensive alternatives. Mycobacterium tuberculosis, which is drugsusceptible or drug-resistant, is effectively treated by several already prescribed medications and their derivatives. Due to this, the current review attempts to give a brief overview of the rifampicin derivatives that can overcome the parent drug's resistance and could, hence, act as useful substitutes. It has been found that one-third of the global population is affected by M. tuberculosis. The most common cause of infection-related death can range from latent TB to TB illness. Antibiotics in the rifamycin class, including rifampicin or rifampin (RIF), rifapentine (RPT), and others, have a special sterilizing effect on M. tuberculosis. We examine research focused on evaluating the safety, effectiveness, pharmacokinetics, pharmacodynamics, risk of medication interactions, and other characteristics of RIF analogs. Drug interactions are especially difficult with RIF because it must be taken every day for four months to treat latent TB infection. RIF continues to be the gold standard of treatment for drug-sensitive TB illness. RIF's safety profile is well known, and the two medicines' adverse reactions have varying degrees of frequency. The authorized once-weekly RPT regimen is insufficient, but greater dosages of either medication may reduce the amount of time needed to treat TB effectively.
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Affiliation(s)
- Mohammad Asif
- Department of Pharmaceutical Chemistry, Era College of Pharmacy, Era University, Lucknow, 226003, Uttar Pradesh, India
| | - Naeem F Qusty
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al‒Qura University, Makkah, 21955, Saudi Arabia
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al‒Qura University, Makkah, 21955, Saudi Arabia
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10
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Khadka P, Dummer J, Hill PC, Das SC. The quest to deliver high-dose rifampicin: can the inhaled approach help? Expert Opin Drug Deliv 2024; 21:31-44. [PMID: 38180078 DOI: 10.1080/17425247.2024.2301931] [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: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Tuberculosis (TB) is a global health problem that poses a challenge to global treatment programs. Rifampicin is a potent and highly effective drug for TB treatment; however, higher oral doses than the standard dose (10 mg/kg/day) rifampicin may offer better efficacy in TB treatment. AREAS COVERED High oral dose rifampicin is not implemented in anti-TB regimens yet and requires about a 3-fold increase in dose for increased efficacy. We discuss inhaled delivery of rifampicin as an alternative or adjunct to oral high-dose rifampicin. Clinical results of safety, tolerability, and patient compliance with antibiotic dry powder inhalers are reviewed. EXPERT OPINION Clinical trials suggest that an approximately 3-fold increase in the standard oral dose of rifampicin may be required for better clinical outcomes. On the other hand, animal studies suggest that inhaled rifampicin can deliver a high concentration of the drug to the lungs and achieve approximately double the plasma concentration than that from oral rifampicin. Clinical trials on inhaled antibiotics suggest that dry powder inhalation is a patient-friendly and well-tolerated approach in treating respiratory infections compared to conventional treatments. Rifampicin, a well-known anti-TB drug given orally, is a good candidate for clinical development as a dry powder inhaler.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jack Dummer
- Department of Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Philip C Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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11
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Deng F, Chen B, Guo H, Chen Q, Wang F. Effectiveness and safety analysis of titanium mesh grafting versus bone grafting in the treatment of spinal Tuberculosis: a systematic review and meta-analysis. BMC Surg 2023; 23:377. [PMID: 38087216 PMCID: PMC10717474 DOI: 10.1186/s12893-023-02283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND To systematically assess the safety and effectiveness of titanium mesh grafting compared with bone grafting in the treatment of spinal tuberculosis. METHODS Electronic databases, including PubMed, Embase, Web of Science, and Cochrane Library, were searched from their inception until April 2023. The outcome indicators for patients treated with titanium mesh grafting or bone grafting for spinal tuberculosis include surgical duration, intraoperative blood loss, graft fusion time, American Spinal Injury Association (ASIA) Spinal Cord Injury Grade E assessment, VAS score, lumbar pain score, post-graft kyphotic angle, and postoperative complications. The Newcastle-Ottawa Scale (NOS) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach were used for quality assessment and evidence grading of clinical studies. Funnel plots and Begg's test were employed for bias assessment. RESULTS A total of 8 studies were finally included, comprising 523 patients, with 267 cases of titanium mesh fixation and 256 cases of bone grafting. The meta-analysis showed no significant statistical differences in surgical duration (Weighted Mean Difference (WMD) = -7.20, 95% Confidence Interval (CI): -28.06 to 13.67, P = 0.499), intraoperative blood loss (WMD = 16.22, 95% CI: -40.62 to 73.06, P = 0.576), graft fusion time (WMD = 0.97, 95% CI: -0.88 to 2.81, P = 0.304), ASIA Spinal Cord Injury Grade E assessment (Relative Risk (RR) = 1.03, 95% CI: 0.97 to 1.09, P = 0.346), and overall complications (RR = 0.87, 95% CI: 0.49 to 1.55, P = 0.643). Differences in VAS score, ODI lumbar pain score, and post-graft kyphotic angle between the titanium mesh grafting group and the bone grafting group were not significant within the 95% CI range. The rate of postoperative implant subsidence was slightly lower in bone grafting than in titanium mesh grafting (RR = 9.30, 95% CI: 1.05 to 82.22, P = 0.045). CONCLUSIONS Both bone grafting and titanium mesh grafting are effective and safe for the surgery, with no significant statistical differences in the results. Considering the limitations of the present study, large-scale randomized controlled trials are warranted to further verify the reliability of this finding.
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Affiliation(s)
- Fangfang Deng
- The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang Hubei, 443000, China
| | - Bo Chen
- The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang Hubei, 443000, China
| | - Huali Guo
- The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang Hubei, 443000, China
| | - Qingqing Chen
- The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang Hubei, 443000, China
| | - Feifan Wang
- The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang Hubei, 443000, China.
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Singh S, Gumbo T, Alffenaar JW, Boorgula GD, Shankar P, Thomas TA, Dheda K, Malinga L, Raj P, Aryal S, Srivastava S. Meropenem-vaborbactam restoration of first-line drug efficacy and comparison of meropenem-vaborbactam-moxifloxacin versus BPaL MDR-TB regimen. Int J Antimicrob Agents 2023; 62:106968. [PMID: 37726063 PMCID: PMC10850916 DOI: 10.1016/j.ijantimicag.2023.106968] [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: 07/06/2023] [Revised: 08/31/2023] [Accepted: 09/09/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Meropenem in combination with β-lactamase inhibitors (BLIs) and other drugs was tested to identify alternative treatment regimens for multidrug-resistant tuberculosis (MDR-TB). METHODS The following were performed: (1) MIC experiments; (2) static time-kill studies (STKs) with different BLIs; and (3) a hollow fibre model system of TB (HFS-TB) studies with meropenem-vaborbactam combined with human equivalent daily doses of 20 mg/kg or 35 mg/kg rifampin, or moxifloxacin 400 mg, or linezolid 600 mg vs. bedaquiline-pretonamid-linezolid (BPaL) for MDR-TB. The studies were performed using Mycobacterium tuberculosis (M. tuberculosis) H37Rv and an MDR-TB clinical strain (named M. tuberculosis 16D) that underwent whole genome sequencing. Exponential decline models were used to calculate the kill rate constant (K) of different HFS-TB regimens. RESULTS Whole genome sequencing revealed mutations associated with resistance to rifampin, isoniazid, and cephalosporins. The meropenem-vaborbactam MIC of M. tuberculosis was H37Rv 2 mg/L and > 128 mg/L for M. tuberculosis 16D. Relebactam and vaborbactam improved both the potency and efficacy of meropenem in STKs. Meropenem-vaborbactam alone failed to kill M. tuberculosis 16D but killed below day 0 burden when combined with isoniazid and rifampin, with the moxifloxacin combination being the most effective and outranking bedaquiline and pretomanid. In the HFS-TB, meropenem-vaborbactam-moxifloxacin and BPaL had the highest K (log10 cfu/mL/day) of 0.31 (95% CI 0.17-0.58) and 0.34 (95% CI 0.21-0.56), while meropenem-vaborbactam-rifampin (35 mg/kg) had a K of 0.18 (95% CI 0.12-0.25). The K for meropenem-vaborbactam-moxifloxacin-linezolid demonstrated antagonism. CONCLUSION Adding meropenem-vaborbactam could potentially restore the efficacy of isoniazid and rifampin against MDR-TB. The meropenem-vaborbactam-moxifloxacin backbone regimen has implications for creating a new effective MDR-TB regimen.
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Affiliation(s)
- Sanjay Singh
- Department of Medicine, School of Medicine, University of Texas at Tyler, Tyler, TX, USA
| | - Tawanda Gumbo
- Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc., Dallas, TX, USA; Hollow Fiber System & Experimental Therapeutics Laboratories, Praedicare Inc, Dallas, TX, USA
| | - Jan-Willem Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, New South Wales, Australia; School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia
| | - Gunavanthi D Boorgula
- Department of Medicine, School of Medicine, University of Texas at Tyler, Tyler, TX, USA
| | - Prem Shankar
- Department of Medicine, School of Medicine, University of Texas at Tyler, Tyler, TX, USA
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Keertan Dheda
- The Center for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lesibana Malinga
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Prithvi Raj
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Santosh Aryal
- Department of Pharmaceutical Sciences and Health Outcomes, The Ben and Maytee Fisch College of Pharmacy, University of Texas at Tyler, Tyler, TX, USA
| | - Shashikant Srivastava
- Department of Medicine, School of Medicine, University of Texas at Tyler, Tyler, TX, USA; Department of Cellular and Molecular Biology, UT Health Science Centre at Tyler, Tyler, TX, US.
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Seo WJ, Koo HK, Kang JY, Kang J, Park SH, Kang HK, Park HK, Lee SS, Choi S, Jang TW, Shin KC, Oh JY, Choi JY, Min J, Choi YK, Shin JG, Cho YS. Risk adjustment model for tuberculosis compared to non-tuberculosis mycobacterium or latent tuberculosis infection: Center for Personalized Precision Medicine of Tuberculosis (cPMTb) cohort database. BMC Pulm Med 2023; 23:471. [PMID: 38001469 PMCID: PMC10675857 DOI: 10.1186/s12890-023-02646-7] [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: 02/06/2023] [Accepted: 09/08/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The Center for Personalized Precision Medicine of Tuberculosis (cPMTb) was constructed to develop personalized pharmacotherapeutic systems for tuberculosis (TB). This study aimed to introduce the cPMTb cohort and compare the distinct characteristics of patients with TB, non-tuberculosis mycobacterium (NTM) infection, or latent TB infection (LTBI). We also determined the prevalence and specific traits of polymorphisms in N-acetyltransferase-2 (NAT2) and solute carrier organic anion transporter family member 1B1 (SLCO1B1) phenotypes using this prospective multinational cohort. METHODS Until August 2021, 964, 167, and 95 patients with TB, NTM infection, and LTBI, respectively, were included. Clinical, laboratory, and radiographic data were collected. NAT2 and SLCO1B1 phenotypes were classified by genomic DNA analysis. RESULTS Patients with TB were older, had lower body mass index (BMI), higher diabetes rate, and higher male proportion than patients with LTBI. Patients with NTM infection were older, had lower BMI, lower diabetes rate, higher previous TB history, and higher female proportion than patients with TB. Patients with TB had the lowest albumin levels, and the prevalence of the rapid, intermediate, and slow/ultra-slow acetylator phenotypes were 39.2%, 48.1%, and 12.7%, respectively. The prevalence of rapid, intermediate, and slow/ultra-slow acetylator phenotypes were 42.0%, 44.6%, and 13.3% for NTM infection, and 42.5%, 48.3%, and 9.1% for LTBI, respectively, which did not differ significantly from TB. The prevalence of the normal, intermediate, and lower transporter SLCO1B1 phenotypes in TB, NTM, and LTBI did not differ significantly; 74.9%, 22.7%, and 2.4% in TB; 72.0%, 26.1%, and 1.9% in NTM; and 80.7%, 19.3%, and 0% in LTBI, respectively. CONCLUSIONS Understanding disease characteristics and identifying pharmacokinetic traits are fundamental steps in optimizing treatment. Further longitudinal data are required for personalized precision medicine. TRIAL REGISTRATION This study registered ClinicalTrials.gov NO. NCT05280886.
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Affiliation(s)
- Woo Jung Seo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hyeon-Kyoung Koo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Ji Yeon Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jieun Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - So Hee Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hye Kyeong Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Sung-Soon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Sangbong Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Tae Won Jang
- Division of Pulmonary, Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Kyeong-Cheol Shin
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Yeungnam University, Yeungman University Medical Center, Daegu, Korea
| | - Jee Youn Oh
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Joon Young Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Jinsoo Min
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young-Kyung Choi
- Center for Personalized Precision Medicine of Tuberculosis (cPMTb), Inje University College of Medicine, Busan, 47392, Korea
- Department of Pharmacology and Clinical Pharmacology, Pharmacogenomics Research Center, Inje University College of Medicine, Busan, Republic of Korea
| | - Jae-Gook Shin
- Center for Personalized Precision Medicine of Tuberculosis (cPMTb), Inje University College of Medicine, Busan, 47392, Korea.
- Department of Pharmacology and Clinical Pharmacology, Pharmacogenomics Research Center, Inje University College of Medicine, Busan, Republic of Korea.
| | - Yong-Soon Cho
- Center for Personalized Precision Medicine of Tuberculosis (cPMTb), Inje University College of Medicine, Busan, 47392, Korea.
- Department of Pharmacology and Clinical Pharmacology, Pharmacogenomics Research Center, Inje University College of Medicine, Busan, Republic of Korea.
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Pan J, Chang Z, Zhang X, Dong Q, Zhao H, Shi J, Wang G. Research progress of single-cell sequencing in tuberculosis. Front Immunol 2023; 14:1276194. [PMID: 37901241 PMCID: PMC10611525 DOI: 10.3389/fimmu.2023.1276194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/29/2023] [Indexed: 10/31/2023] Open
Abstract
Tuberculosis is a major infectious disease caused by Mycobacterium tuberculosis infection. The pathogenesis and immune mechanism of tuberculosis are not clear, and it is urgent to find new drugs, diagnosis, and treatment targets. A useful tool in the quest to reveal the enigmas related to Mycobacterium tuberculosis infection and disease is the single-cell sequencing technique. By clarifying cell heterogeneity, identifying pathogenic cell groups, and finding key gene targets, the map at the single cell level enables people to better understand the cell diversity of complex organisms and the immune state of hosts during infection. Here, we briefly reviewed the development of single-cell sequencing, and emphasized the different applications and limitations of various technologies. Single-cell sequencing has been widely used in the study of the pathogenesis and immune response of tuberculosis. We review these works summarizing the most influential findings. Combined with the multi-molecular level and multi-dimensional analysis, we aim to deeply understand the blank and potential future development of the research on Mycobacterium tuberculosis infection using single-cell sequencing technology.
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Affiliation(s)
| | | | | | | | | | - Jingwei Shi
- Key Laboratory of Pathobiology Ministry of Education, College of Basic Medical Sciences/China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| | - Guoqing Wang
- Key Laboratory of Pathobiology Ministry of Education, College of Basic Medical Sciences/China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
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15
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Walter ND, Ernest JP, Dide-Agossou C, Bauman AA, Ramey ME, Rossmassler K, Massoudi LM, Pauly S, Al Mubarak R, Voskuil MI, Kaya F, Sarathy JP, Zimmerman MD, Dartois V, Podell BK, Savic RM, Robertson GT. Lung microenvironments harbor Mycobacterium tuberculosis phenotypes with distinct treatment responses. Antimicrob Agents Chemother 2023; 67:e0028423. [PMID: 37565762 PMCID: PMC10508168 DOI: 10.1128/aac.00284-23] [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: 03/06/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023] Open
Abstract
Tuberculosis lung lesions are complex and harbor heterogeneous microenvironments that influence antibiotic effectiveness. Major strides have been made recently in understanding drug pharmacokinetics in pulmonary lesions, but the bacterial phenotypes that arise under these conditions and their contribution to drug tolerance are poorly understood. A pharmacodynamic marker called the RS ratio® quantifies ongoing rRNA synthesis based on the abundance of newly synthesized precursor rRNA relative to mature structural rRNA. Application of the RS ratio in the C3HeB/FeJ mouse model demonstrated that Mycobacterium tuberculosis populations residing in different tissue microenvironments are phenotypically distinct and respond differently to drug treatment with rifampin, isoniazid, or bedaquiline. This work provides a foundational basis required to address how anatomic and pathologic microenvironmental niches may contribute to long treatment duration and drug tolerance during the treatment of human tuberculosis.
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Affiliation(s)
- Nicholas D. Walter
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
| | - Jackie P. Ernest
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Christian Dide-Agossou
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Allison A. Bauman
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Michelle E. Ramey
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Karen Rossmassler
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lisa M. Massoudi
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Samantha Pauly
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Reem Al Mubarak
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Martin I. Voskuil
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Firat Kaya
- Center for Discovery and Innovation, Nutley, New Jersey, USA
| | | | | | | | - Brendan K. Podell
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Radojka M. Savic
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Gregory T. Robertson
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
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16
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Jindani A, Atwine D, Grint D, Bah B, Adams J, Ticona ER, Shrestha B, Agizew T, Hamid S, Jamil B, Byamukama A, Kananura K, Mugisha Taremwa I, Bonnet M, Camara LM, Bah-Sow OY, Bah KS, Bah NM, Sow M, Ticona Huaroto CE, Mugruza Pineda R, Tandukar B, Raya BB, Shrestha N, Mathoma A, Mathebula-Modongo UP, Basotli J, Irfan M, Begum D, Muzammil A, Ahmed I, Hasan R, Burgos MV, Sultan F, Hassan M, Masood I, Robb C, Decker J, Grubnic S, Butcher PD, Witney A, Dhillon J, Munshi T, Fielding K, Harrison TS. Four-Month High-Dose Rifampicin Regimens for Pulmonary Tuberculosis. NEJM EVIDENCE 2023; 2:EVIDoa2300054. [PMID: 38320155 DOI: 10.1056/evidoa2300054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Shorter but effective tuberculosis treatment regimens would be of value to the tuberculosis treatment community. High-dose rifampicin has been associated with more rapid and secure lung sterilization and may enable shorter tuberculosis treatment regimens. METHODS: We randomly assigned adults who were given a diagnosis of rifampicin-susceptible pulmonary tuberculosis to a 6-month control regimen, a similar 4-month regimen of rifampicin at 1200 mg/d (study regimen 1 [SR1]), or a 4-month regimen of rifampicin at 1800 mg/d (study regimen 2 [SR2]). Sputum specimens were collected at regular intervals. The primary end point was a composite of treatment failure and relapse in participants who were sputum smear positive at baseline. The noninferiority margin was 8 percentage points. Using a sequence of ordered hypotheses, noninferiority of SR2 was tested first. RESULTS: Between January 2017 and December 2020, 672 patients were enrolled in six countries, including 191 in the control group, 192 in the SR1 group, and 195 in the SR2 group. Noninferiority was not shown. Favorable responses rates were 93, 90, and 87% in the control, SR1, and SR2 groups, respectively, for a country-adjusted absolute risk difference of 6.3 percentage points (90% confidence interval, 1.1 to 11.5) comparing SR2 with the control group. The proportions of participants experiencing a grade 3 or 4 adverse event were 4.0, 4.5, and 4.4% in the control, SR1, and SR2 groups, respectively. CONCLUSIONS: Four-month high-dose rifampicin regimens did not have dose-limiting toxicities or side effects but failed to meet noninferiority criteria compared with the standard 6-month control regimen for treatment of pulmonary tuberculosis. (Funded by the MRC/Wellcome Trust/DFID Joint Global Health Trials Scheme; ClinicalTrials.gov number, NCT02581527.)
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Affiliation(s)
- Amina Jindani
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Daniel Atwine
- Epicentre/Mbarara Research Base, Mbarara, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Grint
- London School of Hygiene and Tropical Medicine, London
| | - Boubacar Bah
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | - Jack Adams
- Institute for Infection and Immunity, St. George's, University of London, London
| | | | - Bhabana Shrestha
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | | | - Saeed Hamid
- Aga Khan University Hospital, Karachi, Pakistan
| | | | | | | | | | - Maryline Bonnet
- Epicentre/Mbarara Research Base, Mbarara, Uganda
- University of Montpellier, Recherche translationelles sur le virus de l'immunodéficience humaine et les maladies infectieuses, Institut de recherche pour le developpement, Institut national de la santé et de la recherche médicale, Montpellier, France
| | | | | | - Kindy Sadio Bah
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | - Nene Mamata Bah
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | - Maimouna Sow
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | | | | | - Bijesh Tandukar
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | - Bijendra Bhakta Raya
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | - Neko Shrestha
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | | | | | | | | | | | | | - Imran Ahmed
- Aga Khan University Hospital, Karachi, Pakistan
| | | | - Marcos V Burgos
- Division of Infectious Diseases, University of New Mexico, Albuquerque, NM
| | - Faisal Sultan
- Shaukat Khanum Research Centre and Cancer Hospital, Lahore, Pakistan
| | - Mariam Hassan
- Shaukat Khanum Research Centre and Cancer Hospital, Lahore, Pakistan
| | - Iqra Masood
- Shaukat Khanum Research Centre and Cancer Hospital, Lahore, Pakistan
| | - Claire Robb
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Jonathan Decker
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Sisa Grubnic
- Clinical Academic Group in Infection and Immunity, St. George's University Hospitals National Health Service Foundation Trust, London
| | - Philip D Butcher
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Adam Witney
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Jasvir Dhillon
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Tulika Munshi
- Institute for Infection and Immunity, St. George's, University of London, London
| | | | - Thomas S Harrison
- Institute for Infection and Immunity, St. George's, University of London, London
- Clinical Academic Group in Infection and Immunity, St. George's University Hospitals National Health Service Foundation Trust, London
- Medical Reserach Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
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17
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Chen RH, Michael T, Kuhlin J, Schön T, Stocker S, Alffenaar JWC. Is there a need to optimise pyrazinamide doses in patients with tuberculosis? A systematic review. Int J Antimicrob Agents 2023; 62:106914. [PMID: 37419292 DOI: 10.1016/j.ijantimicag.2023.106914] [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: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023]
Abstract
Pyrazinamide (PZA) is a first-line antituberculosis drug with potent sterilising activity. Variability in drug exposure may translate into suboptimal treatment responses. This systematic review, conducted according to PRISMA guidelines, aimed to evaluate the concentration-effect relationship. In vitro/in vivo studies had to contain information on the infection model, PZA dose and concentration, and microbiological outcome. Human studies had to present information on PZA dose, measures of drug exposure and maximum concentration, and microbiological response parameter or overall treatment outcome. A total of 34 studies were assessed, including in vitro (n = 2), in vivo (n = 3) and clinical studies (n = 29). Intracellular and extracellular models demonstrated a direct correlation between PZA dose of 15-50 mg/kg/day and reduction in bacterial count between 0.50-27.7 log10 CFU/mL. Consistent with this, higher PZA doses (>150 mg/kg) were associated with a greater reduction in bacterial burden in BALB/c mice models. Human pharmacokinetic studies displayed a linear positive correlation between PZA dose (i.e. 21.4-35.7 mg/kg/day) and drug exposure (AUC range 220.6-514.5 mg·h/L). Additionally, human studies confirmed a dose-effect relationship, with an increased 2-month sputum culture conversion rate at AUC/MIC targets of 8.4-11.3 with higher exposure/susceptibility ratios leading to greater efficacy. A 5-fold variability in AUC was observed at PZA dose of 25 mg/kg. A direct concentration-effect relationship and increased treatment efficacy with higher PZA exposure to susceptibility ratios was observed. Taking into account variability in drug exposure and treatment response, further studies on dose optimisation are justified.
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Affiliation(s)
- Ricky Hao Chen
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Toni Michael
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Johanna Kuhlin
- Karolinska Institutet, Department of Medicine Solna, Division of Infectious Diseases, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Schön
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden; Department of Infectious Diseases, Kalmar County Hospital, Linköping University, Kalmar, Sweden
| | - Sophie Stocker
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, The University of New South Wales, Sydney, NSW, Australia; Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia; Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia.
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18
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Xavier RM, Sharumathi SM, Kanniyappan Parthasarathy A, Mani D, Mohanasundaram T. Limited sampling strategies for therapeutic drug monitoring of anti-tuberculosis medications: A systematic review of their feasibility and clinical utility. Tuberculosis (Edinb) 2023; 141:102367. [PMID: 37429151 DOI: 10.1016/j.tube.2023.102367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/12/2023]
Abstract
Therapeutic drug monitoring (TDM) is recommended for medications with high inter-individual variability, narrow therapeutic index drugs, possible drug-drug interactions, drug toxicity, and subtherapeutic concentrations, as well as to assess noncompliance. The area under the plasma concentration-time curve (AUC) is a significant pharmacokinetic parameter since it calculates the drug's total systematic exposure in the body. However, multiple blood samples from the patient are required to calculate the area under the curve, which is inconvenient for both the patient and the healthcare professional. To alleviate the issue, the limited sampling strategy (LSS) was devised, in which sampling is minimized while obtaining complete and precise findings to anticipate the area under the curve. One can reduce costs, labor, and discomfort for patients and healthcare workers by applying this limited sampling strategy. This article examines a systematic evaluation of all the limited sampling done in anti-tuberculosis (anti-TB) medications resulting from the literature search of several research papers. This article also briefly describes the two methodologies: Multiple regression analysis (MRA) and the Bayesian approach used to develop a limited sampling strategy model. Anti-TB medications have been found to have considerable inter-individual variability, and isoniazid has a narrow therapeutic index, both of which are criteria for therapeutic drug monitoring. To avoid multi-drug resistance and therapy failure, it is proposed that limited sampling strategy-based therapeutic drug monitoring of anti-TB medications be undertaken to generate an individualized dose regimen, particularly for individuals at high risk of treatment failure or delayed response.
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Affiliation(s)
- Rinu Mary Xavier
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - S M Sharumathi
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - Arun Kanniyappan Parthasarathy
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - Deepalakshmi Mani
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - Tharani Mohanasundaram
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
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19
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Moestrup PG, Stilling M, Wejse CM, Dahl VN. Mycobacterium marinum: A Challenging Cause of Protracted Tenosynovitis. Antibiotics (Basel) 2023; 12:antibiotics12030629. [PMID: 36978496 PMCID: PMC10045082 DOI: 10.3390/antibiotics12030629] [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: 02/24/2023] [Revised: 03/19/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Mycobacterium marinum infections are rare, and they can be difficult to diagnose and treat. This may lead to further spread of the infection and complications, such as tenosynovitis, pyomyositis, and osteomyelitis. A 40-year-old previously healthy man presented with tenosynovitis of the extensor tendons on the second phalanx of his right hand. He was initially treated with steroid injections without any effect. Followingly, ulceration and an abscess developed on the dorsal site of the hand. At this point, it came to the physician's knowledge that the patient had been cleaning an aquarium before onset of symptoms. After progression to massive tenosynovitis, the patient was admitted and underwent multiple surgical debridements. Briefly, after the first surgery, an interferon-γ release assay was positive, and treatment for M. marinum with rifampicin and azithromycin was initiated after eight months of symptoms. Later, a surgical biopsy showed acid-fast bacilli, and a polymerase chain reaction confirmed the diagnosis of M. marinum. In this case story, we highlight the difficulties of diagnosing and managing this complicated infection, describe the considerable morbidity associated with it, and suggest that local tissue concentrations could be useful to improve clinical outcomes, as these concentrations are potentially suboptimal.
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Affiliation(s)
| | - Maiken Stilling
- Department of Orthopaedics, Aarhus University Hospital, DK-8200 Aarhus N, Denmark
| | | | - Victor Naestholt Dahl
- Department of Infectious Diseases, Aarhus University Hospital, DK-8200 Aarhus N, Denmark
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20
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Pari B, Gallucci M, Ghigo A, Brizzi MF. Insight on Infections in Diabetic Setting. Biomedicines 2023; 11:971. [PMID: 36979949 PMCID: PMC10046483 DOI: 10.3390/biomedicines11030971] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
The correlation between diabetes mellitus and infectious diseases is widely recognized. DM patients are characterized by the impaired function of the immune system. This translates into the occurrence of a variety of infections, including urinary tract, skin and surgical site infections, pneumonia, tuberculosis, and, more recently, SARS-CoV-2. Hyperglycemia has been identified as a relevant factor contributing to unfavorable outcomes in hospitalized patients including SARS-CoV-2 patients. Several studies have been performed proving that to maintain the proper and stringent monitoring of glycemia, a balanced diet and physical activity is mandatory to reduce the risk of infections and their associated complications. This review is focused on the mechanisms accounting for the increased susceptibility of DM patients to infections, with particular attention to the impact of newly introduced hypoglycemic drugs in sepsis management.
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Affiliation(s)
| | | | | | - Maria Felice Brizzi
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
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21
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Garg A, Alam M, Bai S, Dandawate M, Kumari N, Gupta S, Agrawal U, Nagarajan P, Reddy DS, Kulkarni MJ, Mukhopadhyay A. Protective Effects of Rifampicin and Its Analog Rifampicin Quinone in a Mouse Model of Obesity-Induced Type 2 Diabetes. ACS Pharmacol Transl Sci 2023; 6:253-269. [PMID: 36798477 PMCID: PMC9926524 DOI: 10.1021/acsptsci.2c00082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 01/13/2023]
Abstract
Advanced glycation end-products (AGEs) form when glucose reacts non-enzymatically with proteins, leading to abnormal protein function, oxidative stress, and inflammation. AGEs are associated with aging and age-related diseases; their formation is aggravated during diabetes. Therefore, drugs preventing AGE formation can potentially treat diabetic complications, positively affecting health. Earlier, we demonstrated that rifampicin and its analogs have potent anti-glycating activities and increase the life span of Caenorhabditis elegans. This study aimed to investigate the effects of rifampicin during hyperglycemia in C. elegans and in a mouse model of obesity-induced type 2 diabetes. The effects of rifampicin were assessed by determining the life span of C. elegans cultured in the presence of glucose and by measuring HbA1c, AGE levels, and glucose excursions in the diabetic mouse model. Our results show that rifampicin protects C. elegans from glucose-induced toxicity and increases life span. In mice, rifampicin reduces HbA1c and AGEs, improves insulin sensitivity, and reduces indications of diabetic nephropathy without inducing hepatotoxicity. Rifampicin quinone, an analog with lower anti-microbial activity, also reduces HbA1c levels, improves glucose homeostasis and insulin sensitivity, and lowers indications of diabetic nephropathy, without adversely affecting the liver of the diabetic mice. Altogether, our results indicate that rifampicin and its analog have protective roles during diabetes without inflicting hepatic damage and may potentially be considered for repositioning to treat hyperglycemia-related complications in patients.
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Affiliation(s)
- Amit Garg
- Molecular
Aging Laboratory, National Institute of
Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Maroof Alam
- Molecular
Aging Laboratory, National Institute of
Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Shakuntala Bai
- Biochemical
Sciences Division, CSIR-National Chemical
Laboratory, Dr. Homi Bhabha Road, Pune 411008, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Monica Dandawate
- CSIR
− Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
- Organic Chemistry
Division, CSIR-National Chemical Laboratory, Dr. Homi Bhabha Road, Pune 411008, India
| | - Neeta Kumari
- Organic Chemistry
Division, CSIR-National Chemical Laboratory, Dr. Homi Bhabha Road, Pune 411008, India
| | - Sonu Gupta
- Molecular
Aging Laboratory, National Institute of
Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Usha Agrawal
- ICMR-National
Institute of Pathology, Sriramachari Bhawan, Safdarjung Hospital Campus, New Delhi 110029, India
| | - Perumal Nagarajan
- Molecular
Aging Laboratory, National Institute of
Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Dumbala Srinivasa Reddy
- CSIR
− Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
- Organic Chemistry
Division, CSIR-National Chemical Laboratory, Dr. Homi Bhabha Road, Pune 411008, India
| | - Mahesh J. Kulkarni
- Biochemical
Sciences Division, CSIR-National Chemical
Laboratory, Dr. Homi Bhabha Road, Pune 411008, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Arnab Mukhopadhyay
- Molecular
Aging Laboratory, National Institute of
Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
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22
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Noor H, David IG, Jinga ML, Popa DE, Buleandra M, Iorgulescu EE, Ciobanu AM. State of the Art on Developments of (Bio)Sensors and Analytical Methods for Rifamycin Antibiotics Determination. SENSORS (BASEL, SWITZERLAND) 2023; 23:976. [PMID: 36679772 PMCID: PMC9863535 DOI: 10.3390/s23020976] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 06/17/2023]
Abstract
This review summarizes the literature data reported from 2000 up to the present on the development of various electrochemical (voltammetric, amperometric, potentiometric and photoelectrochemical), optical (UV-Vis and IR) and luminescence (chemiluminescence and fluorescence) methods and the corresponding sensors for rifamycin antibiotics analysis. The discussion is focused mainly on the foremost compound of this class of macrocyclic drugs, namely rifampicin (RIF), which is a first-line antituberculosis agent derived from rifampicin SV (RSV). RIF and RSV also have excellent therapeutic action in the treatment of other bacterial infectious diseases. Due to the side-effects (e.g., prevalence of drug-resistant bacteria, hepatotoxicity) of long-term RIF intake, drug monitoring in patients is of real importance in establishing the optimum RIF dose, and therefore, reliable, rapid and simple methods of analysis are required. Based on the studies published on this topic in the last two decades, the sensing principles, some examples of sensors preparation procedures, as well as the performance characteristics (linear range, limits of detection and quantification) of analytical methods for RIF determination, are compared and correlated, critically emphasizing their benefits and limitations. Examples of spectrometric and electrochemical investigations of RIF interaction with biologically important molecules are also presented.
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Affiliation(s)
- Hassan Noor
- Department of Surgery, Faculty of Medicine, “Lucian Blaga” University Sibiu, Lucian Blaga Street 25, 550169 Sibiu, Romania
| | - Iulia Gabriela David
- Department of Analytical Chemistry and Physical Chemistry, Faculty of Chemistry, University of Bucharest, Panduri Av. 90-92, District 5, 050663 Bucharest, Romania
| | - Maria Lorena Jinga
- Department of Analytical Chemistry and Physical Chemistry, Faculty of Chemistry, University of Bucharest, Panduri Av. 90-92, District 5, 050663 Bucharest, Romania
| | - Dana Elena Popa
- Department of Analytical Chemistry and Physical Chemistry, Faculty of Chemistry, University of Bucharest, Panduri Av. 90-92, District 5, 050663 Bucharest, Romania
| | - Mihaela Buleandra
- Department of Analytical Chemistry and Physical Chemistry, Faculty of Chemistry, University of Bucharest, Panduri Av. 90-92, District 5, 050663 Bucharest, Romania
| | - Emilia Elena Iorgulescu
- Department of Analytical Chemistry and Physical Chemistry, Faculty of Chemistry, University of Bucharest, Panduri Av. 90-92, District 5, 050663 Bucharest, Romania
| | - Adela Magdalena Ciobanu
- Department of Psychiatry “Prof. Dr. Al. Obregia” Clinical Hospital of Psychiatry, Berceni Av. 10, District 4, 041914 Bucharest, Romania
- Discipline of Psychiatry, Neurosciences Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Dionisie Lupu Street 37, 020021 Bucharest, Romania
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23
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Espinosa-Pereiro J, Ghimire S, Sturkenboom MGG, Alffenaar JWC, Tavares M, Aguirre S, Battaglia A, Molinas G, Tórtola T, Akkerman OW, Sanchez-Montalva A, Magis-Escurra C. Safety of Rifampicin at High Dose for Difficult-to-Treat Tuberculosis: Protocol for RIAlta Phase 2b/c Trial. Pharmaceutics 2022; 15:pharmaceutics15010009. [PMID: 36678638 PMCID: PMC9864493 DOI: 10.3390/pharmaceutics15010009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/08/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Previous clinical trials for drug-susceptible tuberculosis (DS-TB) have shown that first-line treatment with doses of rifampicin up to 40 mg/kg are safe and increase the early treatment response for young adults with pulmonary tuberculosis. This may lead to a shorter treatment duration for those persons with TB and a good baseline prognosis, or increased treatment success for vulnerable subgroups (age > 60, diabetes, malnutrition, HIV, hepatitis B or hepatitis C coinfection, TB meningitis, stable chronic liver diseases). Here, we describe the design of a phase 2b/c clinical study under the hypothesis that rifampicin at 35 mg/kg is as safe for these vulnerable groups as for the participants included in previous clinical trials. RIAlta is an interventional, open-label, multicenter, prospective clinical study with matched historical controls comparing the standard DS-TB treatment (isoniazid, pyrazinamide, and ethambutol) with rifampicin at 35 mg/kg (HR35ZE group) vs. rifampicin at 10 mg/kg (historical HR10ZE group). The primary outcome is the incidence of grade ≥ 3 Adverse Events or Severe Adverse Events. A total of 134 participants will be prospectively included, and compared with historical matched controls with at least a 1:1 proportion. This will provide a power of 80% to detect non-inferiority with a margin of 8%. This study will provide important information for subgroups of patients that are more vulnerable to TB bad outcomes and/or treatment toxicity. Despite limitations such as non-randomized design and the use of historical controls, the results of this trial may inform the design of future more inclusive clinical trials, and improve the management of tuberculosis in subgroups of patients for whom scientific evidence is still scarce. Trial registration: EudraCT 2020-003146-36, NCT04768231.
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Affiliation(s)
- Juan Espinosa-Pereiro
- International Health Unit Vall d’Hebron-Drassanes, Infectious Diseases Department, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Samiksha Ghimire
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Marieke G. G. Sturkenboom
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Jan-Willem C. Alffenaar
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
- Westmead Hospital, Sydney, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
| | - Margarida Tavares
- Infectious Diseases Service, Centro Hospitalar de São João, 4200-319 Porto, Portugal
| | - Sarita Aguirre
- National Program for Tuberculosis, Ministry of Health, Asunción 1430, Paraguay
| | - Arturo Battaglia
- Instituto Nacional de Enfermedades Respiratorias y Ambientales, Asunción 1430, Paraguay
| | - Gladys Molinas
- Instituto Nacional de Enfermedades Respiratorias y Ambientales, Asunción 1430, Paraguay
| | - Teresa Tórtola
- Microbiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Onno W. Akkerman
- TB Center Beatrixoord, Haren, University Medical Center Groningen, University of Groningen, 9751 ND Groningen, The Netherlands
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Adrian Sanchez-Montalva
- International Health Unit Vall d’Hebron-Drassanes, Infectious Diseases Department, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Grupo de Estudio de Infecciones por Micobacterias, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIM-SEIMC), 28003 Madrid, Spain
- Correspondence:
| | - Cecile Magis-Escurra
- Radboud University Medical Centre, Department of Respiratory Diseases-TB Expert Center Dekkerswald, 6561 KE Nijmegen, The Netherlands
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24
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Alffenaar JWC, de Steenwinkel JEM, Diacon AH, Simonsson USH, Srivastava S, Wicha SG. Pharmacokinetics and pharmacodynamics of anti-tuberculosis drugs: An evaluation of in vitro, in vivo methodologies and human studies. Front Pharmacol 2022; 13:1063453. [PMID: 36569287 PMCID: PMC9780293 DOI: 10.3389/fphar.2022.1063453] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
There has been an increased interest in pharmacokinetics and pharmacodynamics (PKPD) of anti-tuberculosis drugs. A better understanding of the relationship between drug exposure, antimicrobial kill and acquired drug resistance is essential not only to optimize current treatment regimens but also to design appropriately dosed regimens with new anti-tuberculosis drugs. Although the interest in PKPD has resulted in an increased number of studies, the actual bench-to-bedside translation is somewhat limited. One of the reasons could be differences in methodologies and outcome assessments that makes it difficult to compare the studies. In this paper we summarize most relevant in vitro, in vivo, in silico and human PKPD studies performed to optimize the drug dose and regimens for treatment of tuberculosis. The in vitro assessment focuses on MIC determination, static time-kill kinetics, and dynamic hollow fibre infection models to investigate acquisition of resistance and killing of Mycobacterium tuberculosis populations in various metabolic states. The in vivo assessment focuses on the various animal models, routes of infection, PK at the site of infection, PD read-outs, biomarkers and differences in treatment outcome evaluation (relapse and death). For human PKPD we focus on early bactericidal activity studies and inclusion of PK and therapeutic drug monitoring in clinical trials. Modelling and simulation approaches that are used to evaluate and link the different data types will be discussed. We also describe the concept of different studies, study design, importance of uniform reporting including microbiological and clinical outcome assessments, and modelling approaches. We aim to encourage researchers to consider methods of assessing and reporting PKPD of anti-tuberculosis drugs when designing studies. This will improve appropriate comparison between studies and accelerate the progress in the field.
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Affiliation(s)
- Jan-Willem C. Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia,School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia,*Correspondence: Jan-Willem C. Alffenaar,
| | | | | | | | - Shashikant Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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25
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Garcia-Prats AJ, Starke JR, Waning B, Kaiser B, Seddon JA. New Drugs and Regimens for Tuberculosis Disease Treatment in Children and Adolescents. J Pediatric Infect Dis Soc 2022; 11:S101-S109. [PMID: 36314547 DOI: 10.1093/jpids/piac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
After almost 30 years of relative stagnation, research over the past decade has led to remarkable advances in the treatment of both drug-susceptible (DS) and drug-resistant (DR) tuberculosis (TB) disease in children and adolescents. Compared with the previous standard therapy of at least 6 months, 2 new regimens lasting for only 4 months for the treatment of DS-TB have been studied and are recommended by the World Health Organization (WHO), along with a shortened 6-month regimen for treatment of DS-TB meningitis. In addition, the 18- to 24-month regimens previously used for DR-TB that included painful injectable drugs with high rates of adverse effects have been replaced with shorter, safer all-oral regimens. Advances that have improved treatment include development of new TB drugs (bedaquiline, delamanid, pretomanid), reapplication of older TB drugs (rifampicin and rifapentine), and repurposing of other drugs (clofazimine and linezolid). The development of child-friendly formulations for many of these drugs has further enhanced the ability to safely and effectively treat DS- and DR-TB in children and adolescents. The characteristics and use of these drugs, regimens, and formulations are reviewed.
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Affiliation(s)
- Anthony J Garcia-Prats
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Brenda Waning
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - Brian Kaiser
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
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26
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Khadka P, Dummer J, Hill PC, Katare R, Das SC. A review of formulations and preclinical studies of inhaled rifampicin for its clinical translation. Drug Deliv Transl Res 2022; 13:1246-1271. [PMID: 36131190 PMCID: PMC9491662 DOI: 10.1007/s13346-022-01238-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
Inhaled drug delivery is a promising approach to achieving high lung drug concentrations to facilitate efficient treatment of tuberculosis (TB) and to reduce the overall duration of treatment. Rifampicin is a good candidate for delivery via the pulmonary route. There have been no clinical studies yet at relevant inhaled doses despite the numerous studies investigating its formulation and preclinical properties for pulmonary delivery. This review discusses the clinical implications of pulmonary drug delivery in TB treatment, the drug delivery systems reported for pulmonary delivery of rifampicin, animal models, and the animal studies on inhaled rifampicin formulations, and the research gaps hindering the transition from preclinical development to clinical investigation. A review of reports in the literature suggested there have been minimal attempts to test inhaled formulations of rifampicin in laboratory animals at relevant high doses and there is a lack of appropriate studies in animal models. Published studies have reported testing only low doses (≤ 20 mg/kg) of rifampicin, and none of the studies has investigated the safety of inhaled rifampicin after repeated administration. Preclinical evaluations of inhaled anti-TB drugs, such as rifampicin, should include high-dose formulations in preclinical models, determined based on allometric conversions, for relevant high-dose anti-TB therapy in humans.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, 9054, New Zealand
| | - Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
| | - Philip C Hill
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
| | - Rajesh Katare
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, 9054, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, 9054, New Zealand.
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27
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Kwak N, Jeon D, Park Y, Kang YA, Kim KJ, Kim YR, Kwon BS, Kwon YS, Kim HJ, Lee JH, Lee JY, Lee JK, Mok J, Cheon M, Park J, Hahn S, Yim JJ. Treatment shortening of drug-sensitive pulmonary tuberculosis using high-dose rifampicin for 3 months after culture conversion (Hi-DoRi-3): a study protocol for an open-label randomized clinical trial. Trials 2022; 23:666. [PMID: 35978342 PMCID: PMC9387084 DOI: 10.1186/s13063-022-06631-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard treatment regimen for drug-sensitive tuberculosis (TB), comprising four companion drugs, requires a minimum duration of 6 months, and this lengthy treatment leads to poor adherence and increased toxicity. To improve rates of adherence, reduce adverse events, and lower costs, a simplified and shortened treatment regimen is warranted. METHODS This study is a multicenter, open-label randomized clinical trial of non-inferiority design that compares a new regimen with the conventional regimen for drug-sensitive pulmonary TB. The investigational group will use a regimen of high-dose rifampicin (30 mg/kg/day) with isoniazid and pyrazinamide, and the treatment will be maintained for 12 weeks after the achievement of negative conversion of sputum culture. The control group will be treated for 6 months with a World Health Organization-endorsed regimen consisting of isoniazid, rifampicin (10 mg/kg/day), ethambutol, and pyrazinamide. The primary endpoint is the proportion of unfavorable outcomes at 18 months after randomization. Secondary outcomes include time to unfavorable treatment outcome, time to culture conversion on liquid medium, treatment success rate at the end of treatment, proportion of recurrence at 18 months after randomization, time to recurrence after treatment completion, and adverse events of grade 3 or higher during the treatment. We predict a 10% unfavorable outcome for the control group, and 0% difference from the investigational group. Based on 80% verification power and a 2.5% one-sided significance level for a non-inferiority margin of 6%, 393 participants per group are required. Considering the 15% dropout rate, a total of 926 participants (463 in each group) will be recruited. DISCUSSION This study will inform on the feasibility of the treatment regimen using high-dose rifampicin with a shortened and individualized treatment duration for pulmonary TB. TRIAL REGISTRATION ClinicalTrials.gov NCT04485156 . Registered on July 24, 2020.
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Affiliation(s)
- Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Doosoo Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Youngmok Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Kyung Jong Kim
- Department of R&D, Korean Institute of Tuberculosis, Cheongju, South Korea
| | - Young Ran Kim
- Clinical Research Section, International Tuberculosis Research Center, Seoul, South Korea
| | - Byoung Soo Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jeongha Mok
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea
| | - Minkyoung Cheon
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Jiwon Park
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Seokyung Hahn
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea.,Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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28
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Kathamuthu GR, Bhavani PK, Singh M, Saini JK, Aggarwal A, Ansari MSS, Garg R, Babu S. High-Dose Rifampicin Mediated Systemic Alterations of Cytokines, Chemokines, Growth Factors, Microbial Translocation Markers, and Acute-Phase Proteins in Pulmonary Tuberculosis. Front Pharmacol 2022; 13:896551. [PMID: 35910352 PMCID: PMC9335011 DOI: 10.3389/fphar.2022.896551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
High-dose rifampicin (HDR) is now undergoing clinical trials to improve the efficacy of anti-tuberculosis treatment (ATT). However, the influence of HDR in the modulation of different cytokines, chemokines/growth factors, microbial translocation markers (MTMs), and acute-phase proteins (APPs) in pulmonary tuberculosis (PTB) is not well known. PTB individuals were separated into three different arms (R10, R25, and R35) based on their rifampicin dosage. We examined the circulating levels of Type 1, Type 2, pro-inflammatory/regulatory cytokines, chemokines/growth factors, MTMs, and APPs at baseline and after completion of the second month of ATT by ELISA. The baseline levels of cytokines, chemokines/growth factors, MTMs, and APPs did not (except IL-5, IL-6, IL-17A, MCP-1, MIP-1β, GCSF, SAA, ⍺2 MG, Hp) significantly differ between the study individuals. However, at the second month, the plasma levels of Type 1 (TNFα and IFNγ), Type 2 (IL-4, IL-5, and IL-13), pro-inflammatory/regulatory cytokines (IL-6, IL-17A, IL-10, and GMCSF), and APPs were significantly decreased in R35 regimen- compared to R25 and/or R10 regimen-treated PTB individuals. In contrast, the plasma levels of IL-2, IL-8, MCP-1, MIP-1β, GSF, and MTMs were significantly increased in the R35 regimen compared to R25 and/or R10 regimen-treated PTB individuals. Overall, our data reveal that HDR could potentially be beneficial for host immunity by altering different immune and inflammatory markers.
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Affiliation(s)
- Gokul Raj Kathamuthu
- National Institutes of Health-NIRT-International Center for Excellence in Research, Chennai, India
- *Correspondence: Gokul Raj Kathamuthu,
| | | | - Manjula Singh
- Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | | | - Ashutosh Aggarwal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Rajiv Garg
- King George’s Medical University, Lucknow, India
| | - Subash Babu
- National Institutes of Health-NIRT-International Center for Excellence in Research, Chennai, India
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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29
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Alffenaar JWC, Stocker SL, Forsman LD, Garcia-Prats A, Heysell SK, Aarnoutse RE, Akkerman OW, Aleksa A, van Altena R, de Oñata WA, Bhavani PK, Van't Boveneind-Vrubleuskaya N, Carvalho ACC, Centis R, Chakaya JM, Cirillo DM, Cho JG, D Ambrosio L, Dalcolmo MP, Denti P, Dheda K, Fox GJ, Hesseling AC, Kim HY, Köser CU, Marais BJ, Margineanu I, Märtson AG, Torrico MM, Nataprawira HM, Ong CWM, Otto-Knapp R, Peloquin CA, Silva DR, Ruslami R, Santoso P, Savic RM, Singla R, Svensson EM, Skrahina A, van Soolingen D, Srivastava S, Tadolini M, Tiberi S, Thomas TA, Udwadia ZF, Vu DH, Zhang W, Mpagama SG, Schön T, Migliori GB. Clinical standards for the dosing and management of TB drugs. Int J Tuberc Lung Dis 2022; 26:483-499. [PMID: 35650702 PMCID: PMC9165737 DOI: 10.5588/ijtld.22.0188] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.
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Affiliation(s)
- J W C Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - S L Stocker
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Department of Clinical Pharmacology and Toxicology, St Vincent´s Hospital, Sydney, NSW, Australia, St Vincent´s Clinical Campus, University of NSW, Kensington, NSW, Australia
| | - L Davies Forsman
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, Sweden, Department of Infectious Diseases Karolinska University Hospital, Solna, Sweden
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa, Department of Pediatrics, University of Wisconsin, Madison, WI
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - R E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - O W 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
| | - A Aleksa
- Educational Institution "Grodno State Medical University", Grodno, Belarus
| | - R van Altena
- Asian Harm Reduction Network (AHRN) and Medical Action Myanmar (MAM) in Yangon, Myanmar
| | - W Arrazola de Oñata
- Belgian Scientific Institute for Public Health (Belgian Lung and Tuberculosis Association), Brussels, Belgium
| | - P K Bhavani
- Indian Council of Medical Research-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - N Van't Boveneind-Vrubleuskaya
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, Department of Public Health TB Control, Metropolitan Public Health Services, The Hague, The Netherlands
| | - A C C Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos (LITEB), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - R Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - J M Chakaya
- Department of Medicine, Therapeutics and Dermatology, Kenyatta University, Nairobi, Kenya, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - D M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - J G Cho
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, Parramatta Chest Clinic, Parramatta, NSW, Australia
| | - L D Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - M P Dalcolmo
- Reference Center Hélio Fraga, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - P Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - K Dheda
- Centre for Lung Infection and Immunity, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa, University of Cape Town Lung Institute & South African MRC Centre for the Study of Antimicrobial Resistance, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - G J Fox
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia, Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - H Y Kim
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - C U Köser
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - B J Marais
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Department of Infectious Diseases and Microbiology, The Children´s Hospital at Westmead, Westmead, NSW, Australia
| | - I Margineanu
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A G Märtson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Munoz Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, Ciudad de México, Mexico
| | - H M Nataprawira
- Division of Paediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - C W M Ong
- Infectious Disease Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Institute for Health Innovation & Technology (iHealthtech), National University of Singapore, Singapore, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - R Otto-Knapp
- German Central Committee against Tuberculosis (DZK), Berlin, Germany
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - D R Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - R Ruslami
- TB/HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - P Santoso
- Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - R M Savic
- Department of Bioengineering and Therapeutic Sciences, Division of Pulmonary and Critical Care Medicine, Schools of Pharmacy and Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Singla
- Department of TB & Respiratory Diseases, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - E M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - A Skrahina
- The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - D van Soolingen
- National Institute for Public Health and the Environment, TB Reference Laboratory (RIVM), Bilthoven, The Netherlands
| | - S Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - M Tadolini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - T A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Z F Udwadia
- P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - D H Vu
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - W Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, People´s Republic of China
| | - S G Mpagama
- Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania, Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, United Republic of Tanzania
| | - T Schön
- Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden, Institute of Biomedical and Clinical Sciences, Division of Infection and Inflammation, Linköping University, Linköping, Sweden, Department of Infectious Diseases, Kalmar County Hospital, Kalmar, Linköping University, Linköping, Sweden
| | - G B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
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Radtke KK, Svensson EM, van der Laan LE, Hesseling AC, Savic RM, Garcia-Prats AJ. Emerging data on rifampicin pharmacokinetics and approaches to optimal dosing in children with tuberculosis. Expert Rev Clin Pharmacol 2022; 15:161-174. [PMID: 35285351 DOI: 10.1080/17512433.2022.2053110] [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: 11/04/2022]
Abstract
INTRODUCTION Despite its longstanding role in tuberculosis (TB) treatment, there continues to be emerging rifampicin research that has important implications for pediatric TB treatment and outstanding questions about its pharmacokinetics and optimal dose in children. AREAS COVERED This review aims to summarize and discuss emerging data on the use of rifampicin for: 1) routine treatment of drug-susceptible TB; 2) special subpopulations such as children with malnutrition, HIV, or TB meningitis; 3) treatment shortening. We also highlight the implications of these new data for child-friendly rifampicin formulations and identify future research priorities. EXPERT OPINION New data consistently show low rifampicin exposures across all pediatric populations with 10-20 mg/kg dosing. Although clinical outcomes in children are generally good, rifampicin dose optimization is needed, especially given a continued push to shorten treatment durations and for specific high-risk populations of children who have worse outcomes. A pooled analysis of existing data using applied pharmacometrics would answer many of the important questions remaining about rifampicin pharmacokinetics needed to optimize doses, especially in special populations. Targeted clinical studies in children with TB meningitis and treatment shortening with high-dose rifampicin are also priorities.
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Affiliation(s)
- Kendra K Radtke
- Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Elin M Svensson
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Louvina E van der Laan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Radojka M Savic
- Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa.,Department of Pediatrics, University of Wisconsin, Madison, WI, USA
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31
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Muda MR, Harun SN, Syed Sulaiman SA, Sheikh Ghadzi SM. Population Pharmacokinetics Analyses of Rifampicin in Adult and Children Populations: A Systematic Review. Br J Clin Pharmacol 2022; 88:3132-3152. [PMID: 35253251 DOI: 10.1111/bcp.15298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS Rifampicin has become an essential component as the first-line therapy for pulmonary tuberculosis (PTB). Several population pharmacokinetic (PK) studies on rifampicin in the adult and children population have been studied previously. Therefore, the aims of the systematic review were (i) to summarize the relevant published studies and significant covariates that influence the PK of rifampicin across different populations, (ii) to identify any knowledge gap that requires additional research in the future. METHODS A total of 121 relevant population PK articles were systematically identified using PubMed and Scopus from inception to October 2021. Review articles, in-vitro, and physiological methods, animal studies, and noncompartmental analysis were excluded. RESULTS 19 studies which 16 involved adults, two involved children, and one involved both adults and children were included in the review. The structural model of rifampicin can be described as one compartment with a transient compartment absorption model and first-order elimination in most of the studies. Pharmaceutical formulation, body weight, gender, pregnancy status, diabetes, and nutritional supplementation were found to be the significant covariates that affect the PK parameters. External validation of the developed PK model was only conducted in two studies. CONCLUSIONS The source of variability for PK parameters of rifampicin remains inconsistent and poorly understood even though there were many potential covariates investigated in the selected studies. Exploring other possible factors and implementation a strict sampling strategy by considering the induction effects might unravel precise and reliable information. Furthermore, external validation should be frequently conducted to produce better predictability of model performance.
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Affiliation(s)
- Mohd Rahimi Muda
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.,Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Bandar Puncak Alam, Selangor, Malaysia
| | - Sabariah Noor Harun
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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El-Shafie AS, Ahsan I, Radhwani M, Al-Khangi MA, El-Azazy M. Synthesis and Application of Cobalt Oxide (Co3O4)-Impregnated Olive Stones Biochar for the Removal of Rifampicin and Tigecycline: Multivariate Controlled Performance. NANOMATERIALS 2022; 12:nano12030379. [PMID: 35159724 PMCID: PMC8839773 DOI: 10.3390/nano12030379] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 01/27/2023]
Abstract
Cobalt oxide (Co3O4) nanoparticles supported on olive stone biochar (OSBC) was used as an efficient sorbent for rifampicin (RIFM) and tigecycline (TIGC) from wastewater. Thermal stabilities, morphologies, textures, and surface functionalities of two adsorbents; OSBC and Co-OSBC were compared. BET analysis indicated that Co-OSBC possesses a larger surface area (39.85 m2/g) and higher pore-volume compared to the pristine OSBC. FT-IR analysis showed the presence of critical functional groups on the surface of both adsorbents. SEM and EDX analyses showed the presence of both meso- and macropores and confirmed the presence of Co3O4 nanoparticles on the adsorbent surface. Batch adsorption studies were controlled using a two-level full-factorial design (2k-FFD). Adsorption efficiency of Co-OSBC was evaluated in terms of the % removal (%R) and the sorption capacity (qe, mg/g) as a function of four variables: pH, adsorbent dose (AD), drug concentration, and contact time (CT). A %R of 95.18% and 75.48% could be achieved for RIFM and TIGC, respectively. Equilibrium studies revealed that Langmuir model perfectly fit the adsorption of RIFM compared to Freundlich model for TIGC. Maximum adsorption capacity (qmax) for RIFM and TIGC was 61.10 and 25.94 mg/g, respectively. Adsorption kinetics of both drugs could be best represented using the pseudo-second order (PSO) model.
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Affiliation(s)
- Ahmed S. El-Shafie
- Department of Chemistry and Earth Sciences, College of Arts and Sciences, Qatar University, Doha P.O. Box 2713, Qatar; (A.S.E.-S.); (I.A.)
| | - Insharah Ahsan
- Department of Chemistry and Earth Sciences, College of Arts and Sciences, Qatar University, Doha P.O. Box 2713, Qatar; (A.S.E.-S.); (I.A.)
| | - Mohamed Radhwani
- Al Jazeera Academy, Doha P.O. Box 22250, Qatar; (M.R.); (M.A.A.-K.)
| | | | - Marwa El-Azazy
- Department of Chemistry and Earth Sciences, College of Arts and Sciences, Qatar University, Doha P.O. Box 2713, Qatar; (A.S.E.-S.); (I.A.)
- Correspondence:
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33
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Arbiv OA, Kim JM, Yan M, Romanowski K, Campbell JR, Trajman A, Asadi L, Fregonese F, Winters N, Menzies D, Johnston JC. High-dose rifamycins in the treatment of TB: a systematic review and meta-analysis. Thorax 2022; 77:1210-1218. [PMID: 34996847 DOI: 10.1136/thoraxjnl-2020-216497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/02/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is growing interest in using high-dose rifamycin (HDR) regimens in TB treatment, but the safety and efficacy of HDR regimens remain uncertain. We performed a systematic review and meta-analysis comparing HDR to standard-dose rifamycin (SDR) regimens. METHODS We searched MEDLINE, Embase, CENTRAL, Cochrane Database of Systematic Reviews and clinicaltrials.gov for prospective studies comparing daily therapy with HDRs to SDRs. Rifamycins included rifampicin, rifapentine and rifabutin. Our primary outcome was the rate of severe adverse events (SAEs), with secondary outcomes of death, all adverse events, SAE by organ and efficacy outcomes of 2-month culture conversion and relapse. This study was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42020142519). RESULTS We identified 9057 articles and included 13 studies with 6168 participants contributing 7930 person-years (PY) of follow-up (HDR: 3535 participants, 4387 PY; SDR: 2633 participants, 3543 PY). We found no significant difference in the pooled incidence rate ratio (IRR) of SAE between HDR and SDR (IRR 1.00, 95% CI 0.82 to 1.23, I 2=41%). There was no significant difference when analysis was limited to SAE possibly, probably or likely medication-related (IRR 1.07, 95% CI 0.82 to 1.41, I 2=0%); studies with low risk of bias (IRR 0.98, 95% CI 0.79 to 1.20, I 2=44%); or studies using rifampicin (IRR 1.00, 95% CI 0. 0.75-1.32, I 2=38%). No significant differences were noted in pooled outcomes of death, 2-month culture conversion and relapse. CONCLUSIONS HDRs were not associated with a significant difference in SAEs, 2-month culture conversion or death. Further studies are required to identify specific groups who may benefit from HDR.
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Affiliation(s)
- Omri A Arbiv
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JeongMin M Kim
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marie Yan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kamila Romanowski
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,TB Services, BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Anete Trajman
- McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leyla Asadi
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Federica Fregonese
- McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Nicholas Winters
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada
| | - Dick Menzies
- McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,Montreal Chest Institute, McGill University Health Centre, Montreal, Québec, Canada
| | - James C Johnston
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada .,TB Services, BC Centre for Disease Control, Vancouver, British Columbia, Canada.,McGill International TB Centre, McGill University, Montreal, Québec, Canada
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vCOMBAT: a novel tool to create and visualize a computational model of bacterial antibiotic target-binding. BMC Bioinformatics 2022; 23:22. [PMID: 34991453 PMCID: PMC8734216 DOI: 10.1186/s12859-021-04536-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background As antibiotic resistance creates a significant global health threat, we need not only to accelerate the development of novel antibiotics but also to develop better treatment strategies using existing drugs to improve their efficacy and prevent the selection of further resistance. We require new tools to rationally design dosing regimens from data collected in early phases of antibiotic and dosing development. Mathematical models such as mechanistic pharmacodynamic drug-target binding explain mechanistic details of how the given drug concentration affects its targeted bacteria. However, there are no available tools in the literature that allow non-quantitative scientists to develop computational models to simulate antibiotic-target binding and its effects on bacteria. Results In this work, we have devised an extension of a mechanistic binding-kinetic model to incorporate clinical drug concentration data. Based on the extended model, we develop a novel and interactive web-based tool that allows non-quantitative scientists to create and visualize their own computational models of bacterial antibiotic target-binding based on their considered drugs and bacteria. We also demonstrate how Rifampicin affects bacterial populations of Tuberculosis bacteria using our vCOMBAT tool. Conclusions The vCOMBAT online tool is publicly available at https://combat-bacteria.org/. Supplementary Information The online version contains supplementary material available at 10.1186/s12859-021-04536-3.
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Effects of increasing concentrations of rifampicin on different Mycobacterium tuberculosis lineages in a Whole blood Bactericidal Activity Assay. Antimicrob Agents Chemother 2021; 66:e0169921. [PMID: 34871090 DOI: 10.1128/aac.01699-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives: High-dose rifampicin improved bactericidal activity and culture conversion in early-phase trials, done mainly in Africa. We performed a Whole Blood Bactericidal Activity (WBA) study to determine whether the effects of high-dose rifampicin differ across globally-relevant strains; and whether effects are similar in dormant bacilli that will be required for enhancing cure. Methods: Whole blood from healthy volunteers was spiked with rifampicin (range 0.63-60mg/L) and incubated with one of 4 Mycobacterium tuberculosis (Mtb) clinical strains (Haarlem, Latin American-Mediterranean [LAM], East African-Indian [EAI] and Beijing lineages) or a dormant strain (Streptomycin-Starved Mtb 18b strain [ss18b]). Change in bacterial cfu was estimated after inoculation of WBA cultures in MGIT. Results: WBA increased with higher concentrations of rifampicin in all strains. At rifampicin concentrations up to 5mg/L the rate of increase in WBA per unit increase in rifampicin concentration was similar in all 4 clinical strains (p>0.51). Above 5mg/L, EAI (p<0.001) and Beijing (p=0.007) strains showed greater increase in WBA than did LAM; Haarlem was similar to LAM. The dormant strain showed a lower rate of increase in WBA than clinical strains at rifampicin concentrations up to 5mg/L; above 5mg/L the rate of increase was similar to LAM, Beijing and Haarlem strains. Conclusions: Increasing rifampicin concentration enhanced WBA in all strains; the greatest effects were seen in strains common in Asia, suggesting that early-phase trial findings may be generalizable beyond Africa. Similar effects of high concentrations of rifampicin on the dormant strain support the concept that this intervention may enhance sterilizing activity.
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36
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Rifamycin antibiotics and the mechanisms of their failure. J Antibiot (Tokyo) 2021; 74:786-798. [PMID: 34400805 DOI: 10.1038/s41429-021-00462-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
Rifamycins are a class of antibiotics that were first discovered in 1957 and are known for their use in treating tuberculosis (TB). Rifamycins exhibit bactericidal activity against many Gram-positive and Gram-negative bacteria by inhibiting RNA polymerase (RNAP); however, resistance is prevalent and the mechanisms range from primary target modification and antibiotic inactivation to cytoplasmic exclusion. Further, phenotypic resistance, in which only a subpopulation of bacteria grow in concentrations exceeding their minimum inhibitory concentration, and tolerance, which is characterized by reduced rates of bacterial cell death, have been identified as additional causes of rifamycin failure. Here we summarize current understanding and recent developments regarding this critical antibiotic class.
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Muliaditan M, Della Pasqua O. Bacterial growth dynamics and pharmacokinetic-pharmacodynamic relationships of rifampicin and bedaquiline in BALB/c mice. Br J Pharmacol 2021; 179:1251-1263. [PMID: 34599506 PMCID: PMC9303191 DOI: 10.1111/bph.15688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 08/07/2021] [Accepted: 09/01/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Translational efforts in the evaluation of novel anti-tubercular drugs demand better integration of pharmacokinetic-pharmacodynamic data arising from preclinical protocols. However, parametric approaches that discriminate drug effect from the underlying bacterial growth dynamics have not been fully explored, making it difficult to translate and/or extrapolate preclinical findings to humans. This analysis aims to develop a drug-disease model that allows distinction between drug- and system-specific properties. EXPERIMENTAL APPROACH Given their clinical relevance, rifampicin and bedaquiline were used as test compounds. A two-state model was used to describe bacterial growth dynamics. The approach assumes the existence of fast- and slow-growing bacterial populations. Drug effect on the growth dynamics of each subpopulation was characterised in terms of potency (EC50 -F and EC50 -S) and maximum killing rate. KEY RESULTS The doubling time of the fast- and slow-growing population was estimated to be 25 h and 42 days, respectively. Rifampicin was more potent against the fast-growing (EC50 -F = 4.8 mg·L-1 ), as compared with the slow-growing population (EC50 -S = 60.2 mg·L-1 ). Bedaquiline showed higher potency than rifampicin (EC50 -F = 0.19 mg·L-1 ; EC50 -S = 3.04 mg·L-1 ). External validation procedures revealed an effect of infection route on the apparent potency of rifampicin. CONCLUSION AND IMPLICATIONS Model parameter estimates suggest that nearly maximum killing rate is achieved against fast-growing, but not against slow-growing populations at the tested doses. Evidence of differences in drug potency for each subpopulation may facilitate the translation of preclinical findings and improve the dose rationale for anti-tubercular drugs in humans.
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Affiliation(s)
- Morris Muliaditan
- Clinical Pharmacology & Therapeutics Group, School of Life and Medical Sciences, University College London, London, UK
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, School of Life and Medical Sciences, University College London, London, UK.,Clinical Pharmacology, Modelling and Simulation, GlaxoSmithKline, Brentford, UK
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Garcia-Prats AJ, Svensson EM, Winckler J, Draper HR, Fairlie L, van der Laan LE, Masenya M, Schaaf HS, Wiesner L, Norman J, Aarnoutse RE, Karlsson MO, Denti P, Hesseling AC. Pharmacokinetics and safety of high-dose rifampicin in children with TB: the Opti-Rif trial. J Antimicrob Chemother 2021; 76:3237-3246. [PMID: 34529779 DOI: 10.1093/jac/dkab336] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rifampicin doses of 40 mg/kg in adults are safe and well tolerated, may shorten anti-TB treatment and improve outcomes, but have not been evaluated in children. OBJECTIVES To characterize the pharmacokinetics and safety of high rifampicin doses in children with drug-susceptible TB. PATIENTS AND METHODS The Opti-Rif trial enrolled dosing cohorts of 20 children aged 0-12 years, with incremental dose escalation with each subsequent cohort, until achievement of target exposures or safety concerns. Cohort 1 opened with a rifampicin dose of 15 mg/kg for 14 days, with a single higher dose (35 mg/kg) on day 15. Pharmacokinetic data from days 14 and 15 were analysed using population modelling and safety data reviewed. Incrementally increased rifampicin doses for the next cohort (days 1-14 and day 15) were simulated from the updated model, up to the dose expected to achieve the target exposure [235 mg/L·h, the geometric mean area under the concentration-time curve from 0 to 24 h (AUC0-24) among adults receiving a 35 mg/kg dose]. RESULTS Sixty-two children were enrolled in three cohorts. The median age overall was 2.1 years (range = 0.4-11.7). Evaluated doses were ∼35 mg/kg (days 1-14) and ∼50 mg/kg (day 15) for cohort 2 and ∼60 mg/kg (days 1-14) and ∼75 mg/kg (day 15) for cohort 3. Approximately half of participants had an adverse event related to study rifampicin; none was grade 3 or higher. A 65-70 mg/kg rifampicin dose was needed in children to reach the target exposure. CONCLUSIONS High rifampicin doses in children achieved target exposures and the doses evaluated were safe over 2 weeks.
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Affiliation(s)
- Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa.,Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 2870 University Avenue, Suite 200, Madison, WI 53705, USA
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen (864), The Netherlands.,Department of Pharmacy, Uppsala University, PO Box 580, 751 23 Uppsala, Sweden
| | - Jana Winckler
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Heather R Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute Shandukani CRS, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hilbrow 2001, South Africa
| | - Louvina E van der Laan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Masebole Masenya
- Wits Reproductive Health and HIV Institute Shandukani CRS, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hilbrow 2001, South Africa
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen (864), The Netherlands
| | - Mats O Karlsson
- Department of Pharmacy, Uppsala University, PO Box 580, 751 23 Uppsala, Sweden
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
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Xu RJ, Ling T, Tang H, Ge WH, Jiang Q. Prediction of Rivaroxaban-Rifampin Interaction After Major Orthopedic Surgery: Physiologically Based Pharmacokinetic Modeling and Simulation. Front Pharmacol 2021; 12:706781. [PMID: 34366862 PMCID: PMC8342882 DOI: 10.3389/fphar.2021.706781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/12/2021] [Indexed: 11/15/2022] Open
Abstract
Rivaroxaban is commonly used for the prophylaxis of venous thromboembolism (VTE) for patients undergoing major orthopedic surgery. Rivaroxaban is primarily eliminated by hepatic CYP450 metabolism and renal excretion. Rifampin is a commonly used antibiotic for prosthetic joint infections (PJI) and a potent inducer of CYP450 enzymes. Clinical data about drug-drug interactions of rivaroxaban and rifampin are limited. The present study is to describe DDI of rivaroxaban and rifampin in several prosthetic joint infections patients undergoing major orthopedic surgery. We retrospectively identified six patients concomitantly administered with rivaroxaban and rifampin between 2019 and 2020. Plasma samples of these patients with accurate sampling time were chosen from the biobank and plasma levels of rivaroxaban were measured at each time point. A physiologically based pharmacokinetic model for the rivaroxaban-rifampin interaction was developed to predict the optimal dosing regimen of rivaroxaban in the case of co-medication with rifampin. The model was validated by the observed plasma concentration of rivaroxaban from the above patients. From this model, it could be simulated that when rifampin starts or stops, gradually changing rivaroxaban dose during the first few days would elevate the efficacy and safety of rivaroxaban.
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Affiliation(s)
- Rui-Juan Xu
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China.,Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Tao Ling
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hong Tang
- Department of Analysis, Nanjing GQ Laboratories co., Ltd, Nanjing, China
| | - Wei-Hong Ge
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Qing Jiang
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
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Te Brake LHM, de Jager V, Narunsky K, Vanker N, Svensson EM, Phillips PPJ, Gillespie SH, Heinrich N, Hoelscher M, Dawson R, Diacon AH, Aarnoutse RE, Boeree MJ. Increased bactericidal activity but dose-limiting intolerability at 50 mg·kg -1 rifampicin. Eur Respir J 2021; 58:13993003.00955-2020. [PMID: 33542056 PMCID: PMC8411896 DOI: 10.1183/13993003.00955-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 12/07/2020] [Indexed: 01/16/2023]
Abstract
Background Accumulating data indicate that higher rifampicin doses are more effective and shorten tuberculosis (TB) treatment duration. This study evaluated the safety, tolerability, pharmacokinetics, and 7- and 14-day early bactericidal activity (EBA) of increasing doses of rifampicin. Here we report the results of the final cohorts of PanACEA HIGHRIF1, a dose escalation study in treatment-naive adult smear-positive patients with TB. Methods Patients received, in consecutive cohorts, 40 or 50 mg·kg−1 rifampicin once daily in monotherapy (day 1–7), supplemented with standard dose isoniazid, pyrazinamide and ethambutol between days 8 and 14. Results In the 40 mg·kg−1 cohort (n=15), 13 patients experienced a total of 36 adverse events during monotherapy, resulting in one treatment discontinuation. In the 50 mg·kg−1 cohort (n=17), all patients experienced adverse events during monotherapy, 93 in total; 11 patients withdrew or stopped study medication. Adverse events were mostly mild/moderate and tolerability rather than safety related, i.e. gastrointestinal disorders, pruritis, hyperbilirubinaemia and jaundice. There was a more than proportional increase in the rifampicin geometric mean area under the plasma concentration–time curve from time 0 to 12 h (AUC0–24 h) for 50 mg·kg−1 compared with 40 mg·kg−1; 571 (range 320–995) versus 387 (range 201–847) mg·L−1·h, while peak exposures saw proportional increases. Protein-unbound exposure after 50 mg·kg−1 (11% (range 8–17%)) was comparable with lower rifampicin doses. Rifampicin exposures and bilirubin concentrations were correlated (Spearman's ρ=0.670 on day 3, p<0.001). EBA increased considerably with dose, with the highest seen after 50 mg·kg−1: 14-day EBA −0.427 (95% CI −0.500– −0.355) log10CFU·mL−1·day−1. Conclusion Although associated with an increased bactericidal effect, the 50 mg·kg−1 dose was not well tolerated. Rifampicin at 40 mg·kg−1 was well tolerated and therefore selected for evaluation in a phase IIc treatment-shortening trial. While bactericidal activity continues to increase with dose, for the first time we identified dose-limiting intolerability for rifampicin dosed at 50 mg·kg−1; 40 mg·kg−1 seems the optimal tolerable dose for evaluation in TB treatment-shortening trialshttps://bit.ly/37dUIuB
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Affiliation(s)
- Lindsey H M Te Brake
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Kim Narunsky
- UCT Lung Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Elin M Svensson
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Dept of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Stephen H Gillespie
- School of Medicine, Medical and Biological Sciences, University of St Andrews, St Andrews, UK
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research (DZIF), Munich, Germany
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research (DZIF), Munich, Germany
| | - Rodney Dawson
- UCT Lung Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Rob E Aarnoutse
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Davis AG, Wasserman S, Maxebengula M, Stek C, Bremer M, Daroowala R, Aziz S, Goliath R, Stegmann S, Koekemoer S, Jackson A, Lai Sai L, Kadernani Y, Sihoyiya T, Liang CJ, Dodd L, Denti P, Crede T, Naude J, Szymanski P, Vallie Y, Banderker I, Moosa S, Raubenheimer P, Lai RPJ, Joska J, Nightingale S, Dreyer A, Wahl G, Offiah C, Vorster I, Candy S, Robertson F, Meintjes E, Maartens G, Black J, Meintjes G, Wilkinson RJ. Study protocol for a phase 2A trial of the safety and tolerability of increased dose rifampicin and adjunctive linezolid, with or without aspirin, for HIV-associated tuberculous meningitis [LASER-TBM]. Wellcome Open Res 2021; 6:136. [PMID: 34286103 PMCID: PMC8283551 DOI: 10.12688/wellcomeopenres.16783.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Tuberculous meningitis (TBM) is the most lethal form of tuberculosis with a mortality of ~50% in those co-infected with HIV-1. Current antibiotic regimens are based on those known to be effective in pulmonary TB and do not account for the differing ability of the drugs to penetrate the central nervous system (CNS). The host immune response drives pathology in TBM, yet effective host-directed therapies are scarce. There is sufficient data to suggest that higher doses of rifampicin (RIF), additional linezolid (LZD) and adjunctive aspirin (ASA) will be beneficial in TBM yet rigorous investigation of the safety of these interventions in the context of HIV associated TBM is required. We hypothesise that increased dose RIF, LZD and ASA used in combination and in addition to standard of care for the first 56 days of treatment with be safe and tolerated in HIV-1 infected people with TBM. Methods: In an open-label randomised parallel study, up to 100 participants will receive either; i) standard of care (n=40, control arm), ii) standard of care plus increased dose RIF (35mg/kg) and LZD (1200mg OD for 28 days, 600mg OD for 28 days) (n=30, experimental arm 1), or iii) as per experimental arm 1 plus additional ASA 1000mg OD (n=30, experimental arm 2). After 56 days participants will continue standard treatment as per national guidelines. The primary endpoint is death and the occurrence of solicited treatment-related adverse events at 56 days. In a planned pharmacokinetic (PK) sub-study we aim to assess PK/pharmacodynamic (PD) of oral vs IV rifampicin, describe LZD and RIF PK and cerebrospinal fluid concentrations, explore PK/PD relationships, and investigate drug-drug interactions between LZD and RIF. Safety and pharmacokinetic data from this study will inform a planned phase III study of intensified therapy in TBM. Clinicaltrials.gov registration: NCT03927313 (25/04/2019)
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Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Faculty of Life Sciences, University College London, London, WC1E 6BT, UK.,Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Mpumi Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Cari Stek
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - Marise Bremer
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Remy Daroowala
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - Saalikha Aziz
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Stephani Stegmann
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Sonya Koekemoer
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Louise Lai Sai
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Yakub Kadernani
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Thandi Sihoyiya
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - C Jason Liang
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Lori Dodd
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Thomas Crede
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Jonathan Naude
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Patryk Szymanski
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Yakoob Vallie
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Ismail Banderker
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Shiraz Moosa
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Peter Raubenheimer
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Rachel P J Lai
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - John Joska
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Sam Nightingale
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Anna Dreyer
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Gerda Wahl
- Department of Medicine, Water Sisulu University, Mthatha, 5117, South Africa
| | - Curtis Offiah
- Department of Neuroradiology, Imaging Department, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, UK
| | - Isak Vorster
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory, 7925, South Africa
| | - Sally Candy
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory, 7925, South Africa
| | - Frances Robertson
- MRC/UCT Medical Imaging Research Unit Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Ernesta Meintjes
- MRC/UCT Medical Imaging Research Unit Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - John Black
- Department of Medicine, Water Sisulu University, Mthatha, 5117, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Faculty of Life Sciences, University College London, London, WC1E 6BT, UK.,Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
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Susanto BO, Svensson RJ, Svensson EM, Aarnoutse R, Boeree MJ, Simonsson USH. Rifampicin Can Be Given as Flat-Dosing Instead of Weight-Band Dosing. Clin Infect Dis 2021; 71:3055-3060. [PMID: 31867594 PMCID: PMC7819529 DOI: 10.1093/cid/ciz1202] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/19/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The weight-band dosing in tuberculosis treatment regimen has been implemented in clinical practice for decades. Patients will receive different number of fixed dose combination tablets according to their weight-band. However, some analysis has shown that weight was not the best covariate to explain variability of rifampicin exposure. Furthermore, the rationale for using weight-band dosing instead of flat-dosing becomes questionable. Therefore, this study aimed to compare the average and the variability of rifampicin exposure after weight-band dosing and flat-dosing. METHODS Rifampicin exposure were simulated using previously published population pharmacokinetics model at dose 10-40 mg/kg for weight-band dosing and dose 600-2400 mg for flat-dosing. The median area under the curve (AUC0-24 h) after day 7 and 14 were compared as well as the variability of each dose group between weight-band and flat-dosing. RESULTS The difference of median AUC0-24 h of all dose groups between flat-dosing and weight-band dosing were considered low (< 20%) except for the lowest dose. At the dose of 10 mg/kg (600 mg for flat-dosing), flat-dosing resulted in higher median AUC0-24h compared to the weight-band dosing. A marginal decrease in between-patient variability was predicted for weight-band dosing compared to flat-dosing. CONCLUSIONS Weight-band dosing yields a small and non-clinically relevant decrease in variability of AUC0-24h.
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Affiliation(s)
- Budi O Susanto
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Elin M Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin J Boeree
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Onorato L, Gentile V, Russo A, Di Caprio G, Alessio L, Chiodini P, Coppola N. Standard versus high dose of rifampicin in the treatment of pulmonary tuberculosis: a systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:830-837. [PMID: 33813119 DOI: 10.1016/j.cmi.2021.03.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES A growing amount of evidence suggests that the rifampicin dosing currently recommended for tuberculosis treatment could be associated with inadequate exposure and unfavourable outcomes. We aimed to compare clinical and microbiological efficacy and safety outcomes of standard and higher rifampicin dosing. METHODS Data sources were MEDLINE, Google Scholar and the Cochrane Library. This was a systematic review and meta-analysis that included experimental or observational studies comparing 8-week sputum culture conversion, treatment failure, or safety outcomes in naïve patients with pulmonary tuberculosis treated with standard (10 mg/kg) or higher doses of rifampicin. RESULTS Of a total of 9683 citations screened, eight randomized controlled trials were included, accounting for 1897 subjects; the risk of bias was low in three studies, high in two and intermediate in three. At week 8 a higher proportion of patients in the high-dose group obtained a sputum culture conversion than those in the standard dose group (83.7% versus 80.6%, RR 1.06; 95%CI 1.01-1.12, p 0.028); this result was confirmed in the sub-analysis including patients treated with a rifampicin dose of ≥20 mg/kg, but not in those treated with 11-19 mg/kg. Events of treatment failure at end of treatment showed no significant difference between the two groups (RR 0.84; 95%CI 0.59-1.21, p 0.362). In the analysis evaluating safety outcome, the difference in the occurrence of a grade 3 or 4 liver toxicity or adverse drug reactions leading to discontinuation was not significant at the statistical analysis among the groups (7.2% versus 5.4%, RR 1.19; 95%CI 0.81-1.73, p 0.370, and 1.5% versus 0.6%, RR 2.31; 95%CI 0.65-8.21, p 0.195, respectively). No statistical heterogeneity among studies was observed for each outcome. CONCLUSIONS High doses of rifampicin were associated with an increased rate of sputum culture conversion at 8 weeks of treatment, particularly in patients receiving ≥20 mg/kg.
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Affiliation(s)
- Lorenzo Onorato
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Naples, Italy
| | - Valeria Gentile
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Naples, Italy
| | - Antonio Russo
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Naples, Italy
| | - Giovanni Di Caprio
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Naples, Italy
| | - Loredana Alessio
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Naples, Italy
| | - Paolo Chiodini
- Department of Mental Health and Public Medicine, Section of Statistics, University of Campania, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Naples, Italy.
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Higher Dosing of Rifamycins Does Not Increase Activity against Mycobacterium tuberculosis in the Hollow-Fiber Infection Model. Antimicrob Agents Chemother 2021; 65:AAC.02255-20. [PMID: 33558283 DOI: 10.1128/aac.02255-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/12/2021] [Indexed: 12/18/2022] Open
Abstract
Improvements in the translational value of preclinical models can allow more-successful and more-focused research on shortening the duration of tuberculosis treatment. Although the hollow-fiber infection model (HFIM) is considered a valuable addition to the drug development pipeline, its exact role has not been fully determined yet. Since the strategy of increasing the dose of rifamycins is being evaluated for its treatment-shortening potential, additional in vitro modeling is important. Therefore, we assessed increased dosing of rifampin and rifapentine in our HFIM in order to gain more insight into the place of the HFIM in the drug development pipeline. Total and free-fraction concentrations corresponding to daily dosing of 2.7, 10, and 50 mg of rifampin/kg of body weight, as well as 600 mg and 1,500 mg rifapentine, were assessed in our HFIM using the Mycobacterium tuberculosis H37Rv strain. Drug activity and the emergence of drug resistance were assessed by CFU counting and subsequent mathematical modeling over 14 days, and pharmacokinetic exposures were checked. We found that increasing rifampin exposure above what is expected with the standard dose did not result in higher antimycobacterial activity. For rifapentine, only the highest concentration showed increased activity, but the clinical relevance of this observation is questionable. Moreover, for both drugs, the emergence of resistance was unrelated to exposure. In conclusion, in the simplest experimental setup, the results of the HFIM did not fully correspond to preexisting clinical data. The inclusion of additional parameters and readouts in this preclinical model could be of interest for proper assessment of the translational value of the HFIM.
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Khadka P, Sinha S, Tucker IG, Dummer J, Hill PC, Katare R, Das SC. Studies on the safety and the tissue distribution of inhaled high-dose amorphous and crystalline rifampicin in a rat model. Int J Pharm 2021; 597:120345. [PMID: 33545287 DOI: 10.1016/j.ijpharm.2021.120345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/24/2021] [Accepted: 01/31/2021] [Indexed: 12/17/2022]
Abstract
Inhaled delivery of rifampicin has the potential to achieve high drug concentrations in the lung and the blood for efficient treatment of tuberculosis (TB). Due to its existence as polymorphs, in vivo evaluation of the respiratory tract safety of inhalable amorphous and crystalline rifampicin particles, at clinically relevant high-dose, is necessary. This study investigates the lung and liver safety and the tissue distribution of rifampicin after intra-tracheal administration of high (≥25 mg/kg) doses of amorphous and crystalline powder formulations to Sprague Dawley rats. Powder formulations were administered by intra-tracheal insufflation to rats. Lung and liver safety were evaluated by histopathology. Serum alanine transaminase (ALT) and aspartate aminotransferase (AST) assays were performed to study the hepatic effects. Rifampicin was quantified in the tissues using LC-MS/MS. Intra-tracheal administration of rifampicin decreased the drug burden on the liver compared to oral administration based on its lower serum ALT activity. Repeated-dose intra-tracheal rifampicin was well tolerated by rats, confirmed by the absence of drug or delivery induced complexities. The histopathological evaluation of rat lungs, after both single and repeated drug administration for seven days, suggested the absence of drug-induced toxicity. Following single intra-tracheal delivery of 50 mg/kg doses, comparable rifampicin concentrations to that from same oral dose were observed in lung, liver, heart and brain. Inhaled delivery of high-dose rifampicin was safe to rat lungs and liver suggesting its potential for localized as well as systemic drug delivery without toxicity concerns.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Shubhra Sinha
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, 270 Great King Street, P.O. Box 913, Dunedin 9054, New Zealand
| | - Ian G Tucker
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Philip C Hill
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Rajesh Katare
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, 270 Great King Street, P.O. Box 913, Dunedin 9054, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
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Cresswell FV, Meya DB, Kagimu E, Grint D, te Brake L, Kasibante J, Martyn E, Rutakingirwa M, Quinn CM, Okirwoth M, Tugume L, Ssembambulidde K, Musubire AK, Bangdiwala AS, Buzibye A, Muzoora C, Svensson EM, Aarnoutse R, Boulware DR, Elliott AM. High-Dose Oral and Intravenous Rifampicin for the Treatment of Tuberculous Meningitis in Predominantly Human Immunodeficiency Virus (HIV)-Positive Ugandan Adults: A Phase II Open-Label Randomized Controlled Trial. Clin Infect Dis 2021; 73:876-884. [PMID: 33693537 PMCID: PMC8423465 DOI: 10.1093/cid/ciab162] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND High-dose rifampicin may improve outcomes of tuberculous meningitis (TBM). Little safety or pharmacokinetic (PK) data exist on high-dose rifampicin in human immunodeficiency virus (HIV) coinfection, and no cerebrospinal fluid (CSF) PK data exist from Africa. We hypothesized that high-dose rifampicin would increase serum and CSF concentrations without excess toxicity. METHODS In this phase II open-label trial, Ugandan adults with suspected TBM were randomized to standard-of-care control (PO-10, rifampicin 10 mg/kg/day), intravenous rifampicin (IV-20, 20 mg/kg/day), or high-dose oral rifampicin (PO-35, 35 mg/kg/day). We performed PK sampling on days 2 and 14. The primary outcomes were total exposure (AUC0-24), maximum concentration (Cmax), CSF concentration, and grade 3-5 adverse events. RESULTS We enrolled 61 adults, 92% were living with HIV, median CD4 count was 50 cells/µL (interquartile range [IQR] 46-56). On day 2, geometric mean plasma AUC0-24hr was 42.9·h mg/L with standard-of-care 10 mg/kg dosing, 249·h mg/L for IV-20 and 327·h mg/L for PO-35 (P < .001). In CSF, standard of care achieved undetectable rifampicin concentration in 56% of participants and geometric mean AUC0-24hr 0.27 mg/L, compared with 1.74 mg/L (95% confidence interval [CI] 1.2-2.5) for IV-20 and 2.17 mg/L (1.6-2.9) for PO-35 regimens (P < .001). Achieving CSF concentrations above rifampicin minimal inhibitory concentration (MIC) occurred in 11% (2/18) of standard-of-care, 93% (14/15) of IV-20, and 95% (18/19) of PO-35 participants. Higher serum and CSF levels were sustained at day 14. Adverse events did not differ by dose (P = .34). CONCLUSIONS Current international guidelines result in sub-therapeutic CSF rifampicin concentration for 89% of Ugandan TBM patients. High-dose intravenous and oral rifampicin were safe and respectively resulted in exposures ~6- and ~8-fold higher than standard of care, and CSF levels above the MIC.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom,Infectious Diseases Institute, Makerere University, Kampala, Uganda,Medical Research Council - Uganda Virus Research Institute – LSHTM Uganda Research Unit, Entebbe, Uganda,Correspondence: F. Cresswell, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK ()
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Daniel Grint
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Lindsey te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, The Netherlands
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily Martyn
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | | | - Carson M Quinn
- University of California, San Francisco, San Francisco, California, USA
| | - Micheal Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Division of Biostatistics, University of Minnesota, Minneapolis, Minneapolis, Minnesota, USA
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, The Netherlands,Department of Pharmacy, Uppsala University, Sweden
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, The Netherlands
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minneapolis, Minnesota, USA
| | - Alison M Elliott
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom,Medical Research Council - Uganda Virus Research Institute – LSHTM Uganda Research Unit, Entebbe, Uganda
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Pharmacokinetics of rifampicin after repeated intra-tracheal administration of amorphous and crystalline powder formulations to Sprague Dawley rats. Eur J Pharm Biopharm 2021; 162:1-11. [PMID: 33639255 DOI: 10.1016/j.ejpb.2021.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/14/2021] [Accepted: 02/21/2021] [Indexed: 11/24/2022]
Abstract
Rifampicin is one of the key drugs used to treat tuberculosis and is currently used orally. The use of higher oral doses of rifampicin is desired for better therapeutic efficacy, but this is accompanied by increased risk of systemic toxicity thus limiting its recommended oral dose to 10 mg/kg per day. Inhaled delivery of rifampicin is a potential alternative mode of delivery, to achieve high drug concentrations in both the lung and potentially the systemic circulation. In addition, rifampicin exists either as amorphous or crystalline particles, which may show different pharmacokinetic behaviour. However, disposition behaviour of amorphous and crystalline rifampicin formulations after inhaled high-dose delivery is unknown. In this study, rifampicin pharmacokinetics after intra-tracheal administration of carrier-free, amorphous and crystalline powder formulations to Sprague Dawley rats were evaluated. The formulations were administered once daily for seven days by oral, intra-tracheal and oral plus intra-tracheal delivery, and the pharmacokinetics were studied on day 0 and day 6. Intra-tracheal administration of the amorphous formulation resulted in a higher area under the plasma concentration curve (AUC) compared to the crystalline formulation. For both formulations, the intra-tracheal delivery led to significantly higher AUC compared to the oral delivery at the same dose suggesting higher rifampicin bioavailability from the inhaled route. Increasing the intra-tracheal dose resulted in a more than dose proportional AUC suggesting non-linear pharmacokinetics of rifampicin from the inhaled route. Upon repeated administration for seven days, no significant decrease in the AUCs were observed suggesting the absence of rifampicin induced enzyme auto-induction in this study. The present study suggests an advantage of inhaled delivery of rifampicin in achieving higher drug bioavailability compared to the oral route.
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Svensson EM, Dian S, Te Brake L, Ganiem AR, Yunivita V, van Laarhoven A, Van Crevel R, Ruslami R, Aarnoutse RE. Model-Based Meta-analysis of Rifampicin Exposure and Mortality in Indonesian Tuberculous Meningitis Trials. Clin Infect Dis 2020; 71:1817-1823. [PMID: 31665299 PMCID: PMC7643733 DOI: 10.1093/cid/ciz1071] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/24/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Intensified antimicrobial treatment with higher rifampicin doses may improve outcome of tuberculous meningitis, but the desirable exposure and necessary dose are unknown. Our objective was to characterize the relationship between rifampicin exposures and mortality in order to identify optimal dosing for tuberculous meningitis. METHODS An individual patient meta-analysis was performed on data from 3 Indonesian randomized controlled phase 2 trials comparing oral rifampicin 450 mg (~10 mg/kg) to intensified regimens including 750-1350 mg orally, or a 600-mg intravenous infusion. Pharmacokinetic data from plasma and cerebrospinal fluid (CSF) were analyzed with nonlinear mixed-effects modeling. Six-month survival was described with parametric time-to-event models. RESULTS Pharmacokinetic analyses included 133 individuals (1150 concentration measurements, 170 from CSF). The final model featured 2 disposition compartments, saturable clearance, and autoinduction. Rifampicin CSF concentrations were described by a partition coefficient (5.5%; 95% confidence interval [CI], 4.5%-6.4%) and half-life for distribution plasma to CSF (2.1 hours; 95% CI, 1.3-2.9 hours). Higher CSF protein concentration increased the partition coefficient. Survival of 148 individuals (58 died, 15 dropouts) was well described by an exponentially declining hazard, with lower age, higher baseline Glasgow Coma Scale score, and higher individual rifampicin plasma exposure reducing the hazard. Simulations predicted an increase in 6-month survival from approximately 50% to approximately 70% upon increasing the oral rifampicin dose from 10 to 30 mg/kg, and predicted that even higher doses would further improve survival. CONCLUSIONS Higher rifampicin exposure substantially decreased the risk of death, and the maximal effect was not reached within the studied range. We suggest a rifampicin dose of at least 30 mg/kg to be investigated in phase 3 clinical trials.
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Affiliation(s)
- Elin M Svensson
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Sofiati Dian
- Department of Neurology, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Lindsey Te Brake
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ahmad Rizal Ganiem
- Department of Neurology, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Vycke Yunivita
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Science, Pharmacology and Therapy Division, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Arjan van Laarhoven
- Department of Internal Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinout Van Crevel
- Department of Internal Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rovina Ruslami
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Science, Pharmacology and Therapy Division, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Umumararungu T, Mukazayire MJ, Mpenda M, Mukanyangezi MF, Nkuranga JB, Mukiza J, Olawode EO. A review of recent advances in anti-tubercular drug development. Indian J Tuberc 2020; 67:539-559. [PMID: 33077057 DOI: 10.1016/j.ijtb.2020.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/24/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
Tuberculosis is a global threat but in particular affects people from developing countries. It is thought that nearly a third of the population of the world live with its causative bacteria in a dormant form. Although tuberculosis is a curable disease, the chances of cure become slim as the disease becomes multidrug-resistant and the situation gets even worse as the disease becomes extensively drug-resistant. After approximately 5 decades without any new TB drug in the pipeline, there has been some good news in the recent years with the discovery of new drugs such as bedaquiline and delamanid as well as the discovery of new classes of anti-tubercular drugs. Some old drugs such as clofazimine, linezolid and many others which were not previously indicated for tuberculosis have been also repurposed for tuberculosis and they are performing well.
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Affiliation(s)
- Théoneste Umumararungu
- Department of Pharmacy, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Rwanda.
| | - Marie Jeanne Mukazayire
- Department of Pharmacy, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Rwanda
| | - Matabishi Mpenda
- Department of Pharmacy, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Rwanda
| | - Marie Françoise Mukanyangezi
- Department of Pharmacy, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Rwanda
| | - Jean Bosco Nkuranga
- Department of Chemistry, School of Science, College of Science and Technology, University of Rwanda, Rwanda
| | - Janvier Mukiza
- Department of Mathematical Science and Physical Education, School of Education, College of Education, University of Rwanda, Rwanda
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Khadka P, Hill PC, Zhang B, Katare R, Dummer J, Das SC. A study on polymorphic forms of rifampicin for inhaled high dose delivery in tuberculosis treatment. Int J Pharm 2020; 587:119602. [PMID: 32663580 DOI: 10.1016/j.ijpharm.2020.119602] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/03/2020] [Accepted: 06/29/2020] [Indexed: 12/25/2022]
Abstract
Rifampicin is a first-line, highly effective drug currently used orally as a part of a lengthy multi-drug regimen against tuberculosis (TB). Despite the potential of inhaled therapy as an effective approach for TB treatment, an inhalable formulation of rifampicin has not yet been developed for clinical use. In order to do so, it is necessary to evaluate its solid-state properties, which regulate important characteristics like solubility, dissolution, aerosolization, stability and bioavailability. In this study, a crystallization technique and spray drying were used to prepare inhalable rifampicin formulations. Spray drying yielded amorphous formulation of rifampicin while crystalline dihydrate and pentahydrate formulations were obtained by crystallization. The powders were evaluated for their solid-state properties, in vitro aerosolization and aerosolization stability for three months when stored at different relative humidity conditions. All formulations had a mean particle size smaller than 3.8 µm and had a fine particle fraction (FPF) higher than 58.0%. Amorphous and crystalline dihydrate formulations showed no change in aerosolization parameters (emitted dose and FPF) upon storage for three months. The amorphous and pentahydrate formulations were found to undergo oxidative degradation upon storage, and a decrease in their drug content was observed. Among the formulations prepared, rifampicin dihydrate formulation showed the least degradation over the three months period. The inhalable rifampicin formulations prepared in this study, being excipient free, have the potential to be delivered as inhaled dry powder high-dose rifampicin to the lungs for effective treatment of TB.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Philip C Hill
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Boya Zhang
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Rajesh Katare
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, 270 Great King Street, P.O. Box 913, Dunedin 9054, New Zealand
| | - Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
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