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Thomas L, Raju AP, Mallayasamy S, Rao M. Precision Medicine Strategies to Improve Isoniazid Therapy in Patients with Tuberculosis. Eur J Drug Metab Pharmacokinet 2024; 49:541-557. [PMID: 39153028 PMCID: PMC11365851 DOI: 10.1007/s13318-024-00910-7] [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] [Accepted: 07/15/2024] [Indexed: 08/19/2024]
Abstract
Due to interindividual variability in drug metabolism and pharmacokinetics, traditional isoniazid fixed-dose regimens may lead to suboptimal or toxic isoniazid concentrations in the plasma of patients with tuberculosis, contributing to adverse drug reactions, therapeutic failure, or the development of drug resistance. Achieving precision therapy for isoniazid requires a multifaceted approach that could integrate various clinical and genomic factors to tailor the isoniazid dose to individual patient characteristics. This includes leveraging molecular diagnostics to perform the comprehensive profiling of host pharmacogenomics to determine how it affects isoniazid metabolism, such as its metabolism by N-acetyltransferase 2 (NAT2), and studying drug-resistant mutations in the Mycobacterium tuberculosis genome for enabling targeted therapy selection. Several other molecular signatures identified from the host pharmacogenomics as well as other omics-based approaches such as gut microbiome, epigenomic, proteomic, metabolomic, and lipidomic approaches have provided mechanistic explanations for isoniazid pharmacokinetic variability and/or adverse drug reactions and thereby may facilitate precision therapy of isoniazid, though further validations in larger and diverse populations with tuberculosis are required for clinical applications. Therapeutic drug monitoring and population pharmacokinetic approaches allow for the adjustment of isoniazid dosages based on patient-specific pharmacokinetic profiles, optimizing drug exposure while minimizing toxicity and the risk of resistance. Current evidence has shown that with the integration of the host pharmacogenomics-particularly NAT2 and Mycobacterium tuberculosis genomics data along with isoniazid pharmacokinetic concentrations in the blood and patient factors such as anthropometric measurements, comorbidities, and type and timing of food administered-precision therapy approaches in isoniazid therapy can be tailored to the specific characteristics of both the host and the pathogen for improving tuberculosis treatment outcomes.
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Affiliation(s)
- Levin Thomas
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India
| | - Arun Prasath Raju
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India
| | - Surulivelrajan Mallayasamy
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India.
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Li J, Cai X, Chen Y, Wang C, Jiao Z. Parametric population pharmacokinetics of isoniazid: a systematic review. Expert Rev Clin Pharmacol 2023; 16:467-489. [PMID: 36971782 DOI: 10.1080/17512433.2023.2196401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Isoniazid (INH) plays an important role in prevention and treatment of tuberculosis (TB). However, large pharmacokinetic (PK) variations are observed in patients receiving standard INH dosages. Considering the influence of PK variations on INH efficacy or adverse reactions, we reviewed the population PK studies of INH and explored significant covariates that influence INH PK. METHODS The PubMed and Embase databases were systematically searched from their inception to 30 January 2023. PPK studies on INH using a parametric nonlinear mixed-effect approach were included in this review. The characteristics and identified significant covariates of the included studies were summarized. RESULTS Twenty-one studies conducted in adults, and seven in pediatrics were included. A two-compartment model with first-order absorption and elimination was the frequently used structural model for INH. NAT2 genotype, body size, and age were identified as significant covariates affecting INH PK variation. The median clearance (CL) value in the fast metabolizers was 2.55-fold higher than that in the slow metabolizers. Infants and children had higher CL per weight values than adults with the same metabolic phenotype. In pediatric patients, CL value increased with postnatal age. CONCLUSIONS Compared with slow metabolizers, the daily dose of INH should be increased by 200-600 mg in fast metabolizers. To achieve effective treatment, pediatric patients need a higher dose per kilogram than adults. Further PPK studies of anti-tuberculosis drugs are needed to comprehensively understand the covariates that affect their PK characteristics and to achieve accurate dose adjustments.
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Heyckendorf J, Georghiou SB, Frahm N, Heinrich N, Kontsevaya I, Reimann M, Holtzman D, Imperial M, Cirillo DM, Gillespie SH, Ruhwald M. Tuberculosis Treatment Monitoring and Outcome Measures: New Interest and New Strategies. Clin Microbiol Rev 2022; 35:e0022721. [PMID: 35311552 PMCID: PMC9491169 DOI: 10.1128/cmr.00227-21] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Despite the advent of new diagnostics, drugs and regimens, tuberculosis (TB) remains a global public health threat. A significant challenge for TB control efforts has been the monitoring of TB therapy and determination of TB treatment success. Current recommendations for TB treatment monitoring rely on sputum and culture conversion, which have low sensitivity and long turnaround times, present biohazard risk, and are prone to contamination, undermining their usefulness as clinical treatment monitoring tools and for drug development. We review the pipeline of molecular technologies and assays that serve as suitable substitutes for current culture-based readouts for treatment response and outcome with the potential to change TB therapy monitoring and accelerate drug development.
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Affiliation(s)
- Jan Heyckendorf
- Department of Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | | | - Nicole Frahm
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | - Irina Kontsevaya
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Maja Reimann
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - David Holtzman
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
| | - Marjorie Imperial
- University of California San Francisco, San Francisco, California, USA, United States
| | - Daniela M. Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stephen H. Gillespie
- School of Medicine, University of St Andrewsgrid.11914.3c, St Andrews, Fife, Scotland
| | - Morten Ruhwald
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
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Influence of N-acetyltransferase 2 (NAT2) genotype/single nucleotide polymorphisms on clearance of isoniazid in tuberculosis patients: a systematic review of population pharmacokinetic models. Eur J Clin Pharmacol 2022; 78:1535-1553. [PMID: 35852584 PMCID: PMC9482569 DOI: 10.1007/s00228-022-03362-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/29/2022] [Indexed: 11/19/2022]
Abstract
Purpose Significant pharmacokinetic variabilities have been reported for isoniazid across various populations. We aimed to summarize population pharmacokinetic studies of isoniazid in tuberculosis (TB) patients with a specific focus on the influence of N-acetyltransferase 2 (NAT2) genotype/single-nucleotide polymorphism (SNP) on clearance of isoniazid. Methods A systematic search was conducted in PubMed and Embase for articles published in the English language from inception till February 2022 to identify population pharmacokinetic (PopPK) studies of isoniazid. Studies were included if patient population had TB and received isoniazid therapy, non-linear mixed effects modelling, and parametric approach was used for building isoniazid PopPK model and NAT2 genotype/SNP was tested as a covariate for model development. Results A total of 12 articles were identified from PubMed, Embase, and hand searching of articles. Isoniazid disposition was described using a two-compartment model with first-order absorption and linear elimination in most of the studies. Significant covariates influencing the pharmacokinetics of isoniazid were NAT2 genotype, body weight, lean body weight, body mass index, fat-free mass, efavirenz, formulation, CD4 cell count, and gender. Majority of studies conducted in adult TB population have reported a twofold or threefold increase in isoniazid clearance for NAT2 rapid acetylators compared to slow acetylators. Conclusion The variability in disposition of isoniazid can be majorly attributed to NAT2 genotype. This results in a trimodal clearance pattern with a multi-fold increase in clearance of NAT2 rapid acetylators compared to slow acetylators. Further studies exploring the generalizability/adaptability of developed PopPK models in different clinical settings are required.
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Pharmacometrics in tuberculosis: progress and opportunities. Int J Antimicrob Agents 2022; 60:106620. [PMID: 35724859 DOI: 10.1016/j.ijantimicag.2022.106620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 11/22/2022]
Abstract
Tuberculosis remains one of the leading causes of death by a communicable agent, infecting up to one-quarter of the world's population, predominantly in disadvantaged communities. Pharmacometrics employs quantitative mathematical models to describe the relationships between pharmacokinetics and pharmacodynamics, and to predict drug doses, exposures, and responses. Pharmacometric approaches have provided a scientific basis for improved dosing of antituberculosis drugs and concomitantly administered antiretrovirals at the population level. The development of modelling frameworks including physiologically-based pharmacokinetics, quantitative systems pharmacology and machine learning provides an opportunity to extend the role of pharmacometrics to in silico quantification of drug-drug interactions, prediction of doses for special populations, dose optimization and individualization, and understanding the complex exposure-response relationships of multidrug regimens in terms of both efficacy and safety, informing regimen design for future study. In this short clinically-focused review, we explore what has been done, and what opportunities exist for pharmacometrics to impact tuberculosis pharmacotherapy.
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Said BN, Heysell SK, Yimer G, Aarnoutse RE, Kibiki GS, Mpagama S, Mbelele PM. Pharmacodynamic biomarkers for quantifying the mycobacterial effect of high doses of rifampin in patients with rifampin-susceptible pulmonary tuberculosis. Int J Mycobacteriol 2021; 10:457-462. [PMID: 34916467 PMCID: PMC7612567 DOI: 10.4103/ijmy.ijmy_178_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Suboptimal drug exposure in patients with drug-susceptible tuberculosis (DS-TB) can drive treatment failure. Pharmacodynamics (PD) biomarkers such as the plasma TB drug-activity (TDA) assay may guide dose finding studies and predict microbiological outcomes differently than conventional indices. Methods A study was nested from phase 2b randomized double-blind controlled trial of Tanzanian patients who received a 600 mg, 900 mg, or 1200 mg with a standard dose for DS-TB. Serum at 6 weeks collected over 24-h at 2-h intervals was collected for rifampin area under the concentration-time curve relative to minimum inhibitory concentration (AUC0-24/MIC) or peak concentration and MIC (Cmax/MIC). TDA was the ratio of time-to-positive growth of the patient's Mycobacterium tuberculosis isolates with and without coculture of patient's plasma collected at Cmax. Spearman's rank correlation (r) between PD parameters and culture convention on both liquid and solid culture media. Results Among 10 patients, 600 mg (3), 900 mg (3), and 1200 mg (4) of rifampin dosages. The mean ± standard deviation (SD) of AUC0-24/MIC for patients on 600 mg was 168 ± 159 mg·h/L, on 900 mg was 169 ± 166 mg·h/L, and on 1200 mg was 308 ± 238 mg·h/L. The mean-TDA (SD) was 2.56 (±0.75), 1.5 (±0.59), and 2.29 (±1.08) for patients on 600 mg, 900 mg, and 1200 mg rifampin doses, respectively. Higher TDA values correlated with faster time to culture convention on both liquid (r = -0.55, P = 0.099) and solid media (r = -0.65, P = 0.04). Conclusions TDA and rifampin AUC0-24/MIC did not trend as expected with rifampin dose, but TDA better predicted the time to sputum culture conversion. TDA may provide additional discrimination in predicting treatment response for some regimens distinct from plasma exposure relative to MIC or mg/kg dose.
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Affiliation(s)
- Bibie N Said
- Kibong'oto Infectious Diseases Hospital (KIDH), Research Department, Siha, Kilimanjaro, Tanzania; Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Charlottesville, Virginia, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Getnet Yimer
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Charlottesville, Virginia; Global One Health initiative, Office of International Affairs, The Ohio State University, Columbus, Ohio, USA
| | - Rob E Aarnoutse
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the, Netherlands
| | - Gibson S Kibiki
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Tumaini University, Moshi, Tanzania
| | - Stellah Mpagama
- Kibong'oto Infectious Diseases Hospital (KIDH), Research Department, Siha, Kilimanjaro, Tanzania
| | - Peter M Mbelele
- Kibong'oto Infectious Diseases Hospital (KIDH), Research Department, Siha, Kilimanjaro; Department of Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology (NM-AIST), Arusha, Tanzania
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Nyang'wa BT, Kloprogge F, Moore DAJ, Bustinduy A, Motta I, Berry C, Davies GR. Population pharmacokinetics and pharmacodynamics of investigational regimens' drugs in the TB-PRACTECAL clinical trial (the PRACTECAL-PKPD study): a prospective nested study protocol in a randomised controlled trial. BMJ Open 2021; 11:e047185. [PMID: 34489274 PMCID: PMC8422304 DOI: 10.1136/bmjopen-2020-047185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Drug-resistant tuberculosis (TB) remains a global health threat, with little over 50% of patients successfully treated. Novel regimens like the ones being studied in the TB-PRACTECAL trial are urgently needed. Understanding anti-TB drug exposures could explain the success or failure of these trial regimens. We aim to study the relationship between the patients' exposure to anti-TB drugs in TB-PRACTECAL investigational regimens and their treatment outcomes. METHODS AND ANALYSIS Adults with multidrug-resistant TB randomised to investigational regimens in TB-PRACTECAL will be recruited to a nested pharmacokinetic-pharmacodynamic (PKPD) study. Venous blood samples will be collected at 0, 2 and 23 hours postdose on day 1 and 0, 6.5 and 23 hours postdose during week 8 to quantify drug concentrations in plasma. Trough samples will be collected during week 12, 16, 20 and 24 visits. Opportunistic samples will be collected during weeks 32 and 72. Drug concentrations will be quantified using liquid chromatography-tandem mass spectrometry. Sputum samples will be collected at baseline, monthly to week 24 and then every 2 months to week 108 for MICs and bacillary load quantification. Full blood count, urea and electrolytes, liver function tests, lipase, ECGs and ophthalmology examinations will be conducted at least monthly during treatment.PK and PKPD models will be developed for each drug with nonlinear mixed effects methods. Optimal dosing will be investigated using Monte-Carlo simulations. ETHICS AND DISSEMINATION The study has been approved by the Médecins sans Frontières (MSF) Ethics Review Board, the LSHTM Ethics Committee, the Belarus RSPCPT ethics committee and PharmaEthics and the University of Witwatersrand Human Research ethics committee in South Africa. Written informed consent will be obtained from all participants. The study results will be shared with public health authorities, presented at scientific conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04081077; Pre-results.
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Affiliation(s)
- Bern-Thomas Nyang'wa
- Manson Unit, Médecins Sans Frontières, London, UK
- Clinical research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - David A J Moore
- Clinical research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Amaya Bustinduy
- Clinical research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ilaria Motta
- Manson Unit, Médecins Sans Frontières, London, UK
| | | | - Geraint R Davies
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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Chabala C, Turkova A, Hesseling AC, Zimba KM, van der Zalm M, Kapasa M, Palmer M, Chirehwa M, Wiesner L, Wobudeya E, Kinikar A, Mave V, Hissar S, Choo L, LeBeau K, Mulenga V, Aarnoutse R, Gibb D, McIlleron H. Pharmacokinetics of first-line drugs in children with tuberculosis using WHO-recommended weight band doses and formulations. Clin Infect Dis 2021; 74:1767-1775. [PMID: 34420049 PMCID: PMC9155615 DOI: 10.1093/cid/ciab725] [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: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Dispersible pediatric fixed-dose combination (FDC) tablets delivering higher doses of first-line antituberculosis drugs in World Health Organization–recommended weight bands were introduced in 2015. We report the first pharmacokinetic data for these FDC tablets in Zambian and South African children in the treatment-shortening SHINE trial. Methods Children weighing 4.0–7.9, 8.0–11.9, 12.0–15.9, or 16.0–24.9 kg received 1, 2, 3, or 4 tablets daily, respectively (rifampicin/isoniazid/pyrazinamide [75/50/150 mg], with or without 100 mg ethambutol, or rifampicin/isoniazid [75/50 mg]). Children 25.0–36.9 kg received doses recommended for adults <37 kg (300, 150, 800, and 550 mg/d, respectively, for rifampicin, isoniazid, pyrazinamide, and ethambutol). Pharmacokinetics were evaluated after at least 2 weeks of treatment. Results In the 77 children evaluated, the median age (interquartile range) was 3.7 (1.4–6.6) years; 40 (52%) were male and 20 (26%) were human immunodeficiency virus positive. The median area under the concentration-time curve from 0 to 24 hours for rifampicin, isoniazid, pyrazinamide, and ethambutol was 32.5 (interquartile range, 20.1–45.1), 16.7 (9.2–25.9), 317 (263–399), and 9.5 (7.5–11.5) mg⋅h/L, respectively, and lower in children than in adults for rifampicin in the 4.0–7.9-, 8–11.9-, and ≥25-kg weight bands, isoniazid in the 4.0–7.9-kg and ≥25-kg weight bands, and ethambutol in all 5 weight bands. Pyrazinamide exposures were similar to those in adults. Conclusions Recommended weight band–based FDC doses result in lower drug exposures in children in lower weight bands and in those ≥25 kg (receiving adult doses). Further adjustments to current doses are needed to match current target exposures in adults. The use of ethambutol at the current World Health Organization–recommended doses requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia.,University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anneke C Hesseling
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Kevin M Zimba
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Marieke van der Zalm
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Megan Palmer
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Maxwell Chirehwa
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Lubbe Wiesner
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Louise Choo
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Kristen LeBeau
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Veronica Mulenga
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Robb Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Said B, Charlie L, Getachew E, Wanjiru CL, Abebe M, Manyazewal T. Molecular bacterial load assay versus culture for monitoring treatment response in adults with tuberculosis. SAGE Open Med 2021; 9:20503121211033470. [PMID: 34349999 PMCID: PMC8287413 DOI: 10.1177/20503121211033470] [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] [Received: 01/14/2021] [Accepted: 06/30/2021] [Indexed: 11/16/2022] Open
Abstract
The lack of rapid, sensitive, and deployable tuberculosis diagnostic tools is
hampering the early diagnosis of tuberculosis and early detection of treatment
failures. The conventional sputum smear microscopy or Xpert MTB/RIF assay cannot
distinguish between alive and dead bacilli and the culture method delays
providing results. Tuberculosis molecular bacterial load assay is a reverse
transcriptase real-time quantitative polymerase chain reaction that quantifies
viable tuberculosis bacillary load as a marker of treatment response for
patients on anti-tuberculosis therapy. However, results are not synthesized
enough to inform its comparative advantage to tuberculosis culture technique
which is yet the gold standard of care. With this review, we searched electronic
databases, including PubMed, Embase, and Web of Science, from March 2011 up to
February 2021 for clinical trials or prospective cohort studies that compared
tuberculosis molecular bacterial load assay with tuberculosis culture in adults.
We included eight studies that meet the inclusion criteria. Tuberculosis
molecular bacterial load assay surpasses culture in monitoring patients with
tuberculosis during the first few weeks of anti-tuberculosis treatment. It is
more desirable over culture for its shorter time to results, almost zero rates
of contamination, need for less expertise on the method, early rate of decline,
lower running cost, and reproducibility. Its rapid and specific tuberculosis
treatment monitoring competency benefits patients and healthcare providers to
monitor changes of bacillary load among isolates with drug-susceptible or
resistance to anti-tuberculosis regimens. Despite of the high installing cost of
the tuberculosis molecular bacterial load assay method, molecular expertise, and
a well-equipped laboratory, tuberculosis molecular bacterial load assay is a
cost-effective method with comparison to culture in operational running. To
achieve maximum utility in high tuberculosis burden settings, an intensive
initial investment in nucleic acid extraction and polymerase chain reaction
equipment, training in procedures, and streamlining laboratory supply
procurement systems are crucial. More evidence is needed to demonstrate the
potential large-scale and sustainable use of tuberculosis molecular bacterial
load assay over culture in resource-constrained settings.
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Affiliation(s)
- Bibie Said
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Kibong'oto National Tuberculosis Hospital, Kilimanjaro, Tanzania
| | - Loveness Charlie
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Emnet Getachew
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Public Health, College of Health Science, Arsi University, Asella, Ethiopia
| | - Catherine Lydiah Wanjiru
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mekdelawit Abebe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,St. Peter Tuberculosis Specialized Hospital, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Kloprogge F, Abubakar I, Esmail H, Hack V, Kunst H, McHugh TD, Noursadeghi M, Surey J, Tiberi S, Lipman M. Exploring a combined biomarker for tuberculosis treatment response: protocol for a prospective observational cohort study. BMJ Open 2021; 11:e052885. [PMID: 34244287 PMCID: PMC8268918 DOI: 10.1136/bmjopen-2021-052885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/21/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION An improved understanding of factors explaining tuberculosis (TB) treatment response is urgently needed to help clinicians optimise and personalise treatment and assist scientists undertaking novel treatment regimen trials. Promising outcome proxy measures, including sputum bacillary load and host immune response, are widely reported with variable results. However, they have not been studied together in combination with antibiotic exposure. The aim of this observational cohort study is to investigate which antibiotic exposures correlate with sputum bacillary load and which with the host immune response. Subsequently, we will explore if these correlations can be used to inform a candidate combined biomarker predicting cure. METHODS AND ANALYSIS All patients aged ≥ 18, diagnosed with drug-sensitive pulmonary TB (culture or molecular test), eligible for standard anti-TB treatment, at selected London, UK TB Services, will be invited to participate in this observational cohort study (target sample size=210). Patients will be asked to give blood for host transcriptomics and antibiotic plasma exposure, in addition to standard of care sputum samples for bacillary load. Antibiotic plasma concentrations will be quantified using a validated liquid chromatograph triple quadrupole mass spectrometer (LC-MS/MS) assay and sputum bacillary load by mycobacterial growth incubator tube time to positivity. Expression from a total of 35 prespecified host blood genes will be quantified using NanoString®. Antibiotic exposure, sputum bacillary load and host blood transcriptomic time series data will be analysed using nonlinear mixed-effects models. Correlations between combinations of longitudinal biomarkers and microbiological cure at the end of treatment and remaining relapse free for 1 year thereafter will be analysed using logistic regression and Cox proportional hazard models. ETHICS AND DISSEMINATION The observational cohort study has been approved by the UK's HRA REC (20/SW/0007). Written informed consent will be obtained. Results will be disseminated via publication, presentation and through engagement with institutes/companies developing novel anti-TB treatment combinations.
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Affiliation(s)
- Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Hanif Esmail
- Institute for Global Health, University College London, London, UK
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Vanessa Hack
- Institute for Global Health, University College London, London, UK
| | - Heinke Kunst
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Timothy D McHugh
- UCL Centre for Clinical Microbiology, Division of Infection & Immunity, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, London, UK
| | - Julian Surey
- Institute for Global Health, University College London, London, UK
| | - Simon Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Division of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Marc Lipman
- Respiratory medicine, Royal Free London NHS Foundation Trust, London, UK
- UCL Respiratory, Division of Medicine, University College London, London, UK
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11
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Reves R. Our love-hate relationship with pyrazinamide. Clin Infect Dis 2020; 73:e3518-e3519. [PMID: 33011784 DOI: 10.1093/cid/ciaa1505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Randall Reves
- Division of Infectious Diseases, Department of Medicine and School of Public Health, University of Colorado Denver, Aurora, Colorado
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