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Mondal S, Roy V, Meshram GG, Khanna A, Velpandian T, Garg S. Pharmacokinetics-pharmacodynamics of first-line antitubercular drugs: a comparative study in tuberculosis patients with and without concomitant diabetes mellitus. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03754-x. [PMID: 39287783 DOI: 10.1007/s00228-024-03754-x] [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: 07/13/2024] [Accepted: 08/30/2024] [Indexed: 09/19/2024]
Abstract
PURPOSE To observe the variability in the plasma concentrations and pharmacokinetic-pharmacodynamic (PK-PD) profiles of first-line antitubercular drugs in pulmonary tuberculosis (TB) patients with and without diabetes mellitus (DM). METHODS Newly diagnosed pulmonary TB patients aged 18-60 years with or without DM were included in the study. Group I (n = 20) included patients with TB, whereas group II (n = 20) included patients with both TB and DM. After 2 weeks of therapy, plasma concentrations and other PK-PD parameters were determined. Improvements in clinical features, X-ray findings, sputum conversion, and adverse drug reactions (ADRs) were assessed after 2 months of therapy. RESULTS Isoniazid displayed non-significantly higher plasma concentrations in diabetic patients, along with a significantly (P < 0.05) longer elimination half-life (t1/2). Rifampicin plasma concentrations at 4, 8, and 12 h were significantly (P < 0.05) lower, and it displayed significantly (P < 0.05) lower area under the curve (AUC0-12 and AUC0-∞), shorter t1/2, higher clearance (Cl), and a lower AUC0-∞/MIC ratio in diabetic patients. Pyrazinamide and ethambutol showed non-significantly higher plasma concentrations, AUC0-12, AUC0-∞, and t1/2 in diabetic patients. The improvements in clinical features, X-ray findings, sputum conversion, and ADRs were comparable in both groups. CONCLUSIONS The presence of DM in TB patients affects the PK-PD parameters of isoniazid, rifampicin, pyrazinamide, and ethambutol variably in the Indian population. Studies with a larger number of patients are required to further elucidate the role of DM on the PK-PD profile of first-line antitubercular drugs and treatment outcomes in TB patients with concomitant DM. TRIAL REGISTRATION CTRI/2021/08/035578 dated 11/08/2021.
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Affiliation(s)
- Sourav Mondal
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, 110002, India
- Department of Clinical Pharmacology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, 400012, India
| | - Vandana Roy
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, 110002, India.
| | - Girish Gulab Meshram
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, 110002, India
| | - Ashwani Khanna
- TB and Chest Clinic, Lok Nayak Hospital, New Delhi, 110002, India
| | - Thirumurthy Velpandian
- Department of Ocular Pharmacology and Pharmacy Division of Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sandeep Garg
- Department of General Medicine, Maulana Azad Medical College, New Delhi, 110002, India
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Zhu Y, Forsman LD, Chen C, Zhang H, Shao G, Wang S, Wang S, Xiong H, Bruchfeld J, Wang W, Zhu L, Alffenaar JW, Hu Y. Drug Exposure and Treatment Outcomes in Patients With Multidrug-Resistant Tuberculosis and Diabetes Mellitus: A Multicenter Prospective Cohort Study From China. Clin Infect Dis 2024; 79:524-533. [PMID: 38913750 DOI: 10.1093/cid/ciae329] [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: 03/30/2024] [Revised: 06/04/2024] [Accepted: 06/13/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND The management of multidrug-resistant tuberculosis (MDR-TB) remains challenging. Treatment outcome is influenced by multiple factors; the specific roles of diabetes and glycemic control remain uncertain. This study aims to assess the impact of glycemic control on drug exposure, to investigate the association between drug exposure and treatment outcomes, and to identify clinically significant thresholds predictive of treatment outcome, among patients with diabetes. METHODS This multicenter prospective cohort study involved patients with confirmed MDR-TB and diabetes. Drug exposure level was estimated by noncompartmental analysis. The minimum inhibitory concentrations (MICs) were determined for the individual Mycobacterium tuberculosis isolates. The influence of poor glycemic control (glycated hemoglobin ≥7%) on drug exposure and the associations between drug exposure and treatment outcome were evaluated by univariate and multivariate analysis. Classification and regression tree analysis was used to identify the drug exposure/susceptibility thresholds. RESULTS Among the 131 diabetic participants, 43 (32.8%) exhibited poor glycemic control. Poor glycemic control was independently associated with decreased exposure to moxifloxacin, linezolid, bedaquiline, and cycloserine, but not clofazimine. Additionally, a higher ratio of drug exposure to susceptibility was found to be associated with a favorable MDR-TB treatment outcome. Thresholds predictive of 6-month culture conversion and favorable outcome were bedaquiline area under the concentration-time curve (AUC)/MIC ≥245 and moxifloxacin AUC/MIC ≥67, demonstrating predictive accuracy in patients, regardless of their glycemic control status. CONCLUSIONS Glycemic control and optimal TB drug exposure are associated with improved treatment outcomes. This dual management strategy should be further validated in randomized controlled trials of patients with MDR-TB and diabetes.
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Affiliation(s)
- Yue Zhu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Lina Davies Forsman
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Division of Infectious Diseases, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Cheng Chen
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Haoyue Zhang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Ge Shao
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Sainan Wang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Shanshan Wang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Haiyan Xiong
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Judith Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Division of Infectious Diseases, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Weibing Wang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Limei Zhu
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney, Australia
- Department of Clinical Pharmacology, Westmead Hospital, Sydney, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, Australia
| | - Yi Hu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
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Danso EK, Asare P, Osei-Wusu S, Tetteh P, Tetteh AY, Boadu AA, Lamptey INK, Sylverken AA, Obiri-Danso K, Afriyie Mensah J, Adjei A, Yeboah-Manu D. Tuberculosis patients with diabetes co-morbidity experience reduced Mycobacterium tuberculosis complex clearance. Heliyon 2024; 10:e35670. [PMID: 39170565 PMCID: PMC11336890 DOI: 10.1016/j.heliyon.2024.e35670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/25/2024] [Accepted: 08/01/2024] [Indexed: 08/23/2024] Open
Abstract
Objective This study aimed to investigate the impact of diabetes mellitus (DM) on tuberculosis (TB) treatment response using bacterial clearance as a surrogate marker. Method We compared smear microscopy, culture, and tuberculosis molecular bacterial load assay (TB-MBLA) for treatment monitoring. Following that, bacterial clearance was longitudinally monitored among TB-only (TB without DM) and TB-diabetes (TBDM) patients using TB-MBLA. Results Ninety-three participants, including 59 TB-only and 34 TBDM patients, were enrolled. TB-only patients exhibited higher upper zone infiltrations (32/35 vs 16/22, p = 0.059) suggesting a trend towards significance, and significantly more cavitation in the same zone (16/18 vs 7/13, p = 0.028). There was a high proportion of Mycobacterium africanum (Maf) among the TBDM cohort (p = 0.0044).At baseline, TB-only patients exhibited a higher average bacterial burden (4.49 logeCFU/mL) compared to the TBDM group (3.91 logeCFU/mL) (p = 0.042). The bacterial load in the TB-only group decreased significantly during treatment but the TBDM group experienced delayed clearance throughout the intensive phase of anti-TB treatment even at day 56 (p = 0.028). The TB-only group demonstrated a shorter median time to TB-MBLA conversion to negative (57 days) compared to the TBDM group (62 days) (p = 0.022). Conclusion These findings underscore the urgent call for understanding the interplay between diabetes and TB, emphasizing the need for tailored interventions in optimizing TB care for individuals comorbid with diabetes.
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Affiliation(s)
- Emelia Konadu Danso
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Prince Asare
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Stephen Osei-Wusu
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Phillip Tetteh
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Amanda Yaa Tetteh
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Augustine Asare Boadu
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Ivy Naa Koshie Lamptey
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Augustina Angelina Sylverken
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwasi Obiri-Danso
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Abraham Adjei
- Department of Chest Diseases, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Dorothy Yeboah-Manu
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
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Singla R, Gupta A, Kumar V, Padmapriyadarsini C, Tayal D, Anand S, Faye A, Kumar AH, Choudhary MP. Study of risk factors and clinical management of patients with clinical non-response due to low plasma levels of anti-tubercular drugs. Monaldi Arch Chest Dis 2024. [PMID: 39058042 DOI: 10.4081/monaldi.2024.3036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 07/28/2024] Open
Abstract
This study was carried out to assess the role of therapeutic drug monitoring of crucial first-line anti-tubercular drugs: rifampicin (R) and isoniazid (H) among 75 non-responding proven drug-sensitive tuberculosis patients on treatment followed by intervention in field conditions. The intervention was done in the form of either an increase in the dosage of R and H in patients with minimally low drug levels or a modification of the regimen in a certain group of patients with significantly low drug levels by augmenting it with three or four second-line drugs in addition to standard first-line drugs. This study also aimed to determine the relationship between the measured plasma concentration of anti-tubercular drugs and various demographic, microbiological, radiological, and malabsorption factors and the presence of co-morbidities affecting them. The study also focused on the clinical impact of the intervention for low plasma levels of anti-TB drugs on TB treatment outcomes. In our study overall, 85.5% of patients had low levels of any drug. In 85.3% of patients, R levels were low, and in 39.1%, H levels were low. On univariate analysis, low body mass index (BMI), hypoalbuminemia, bilateral disease on chest X-rays, and the presence of cavities were found to be significantly associated with low drug levels, while none of the factors were independently significantly associated. Low BMI, pulmonary tuberculosis and disseminated tuberculosis, far-advanced disease and bilateral disease on chest X-ray, presence of cavities, and only low R levels were associated with unfavorable outcomes, with none of the factors found to be significant on multivariate analysis. In our study, it was seen that the treatment outcome was favorable in 59.6% of patients in whom this intervention was done by augmenting the treatment regimen with three/four second-line drugs along with increasing the dose of R and H. To conclude, various factors may be associated with low plasma levels of anti-tubercular drugs. If such patients show clinical non-response after >6 months of treatment and have significantly low drug levels, with an absence of drug resistance, their treatment regimen may need augmentation with three/four second-line drugs along with an increase in the dose of R and H, which may lead to a favorable outcome.
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Affiliation(s)
- Rupak Singla
- Department of Tuberculosis and Chest Diseases, National Institute of Tuberculosis and Respiratory Diseases, New Delhi.
| | - Amitesh Gupta
- Department of Pulmonary Medicine, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi.
| | - Vikas Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS Raipur, Chhattisgarh.
| | | | - Devika Tayal
- Department of Biochemistry, National Institute of Tuberculosis and Respiratory Diseases, New Delhi.
| | - Shweta Anand
- Department of Pulmonary, Critical Care and Sleep Medicine, ESI PGIMSR, Basaidarapur, New Delhi.
| | - Abhishek Faye
- Center for Lung and Sleep Disorders, Nagpur, Maharashtra.
| | - Ak Hemanth Kumar
- Department of Clinical Pharmacology, ICMR - National Institute of Research in Tuberculosis, Chennai.
| | - Madhumita Paul Choudhary
- Department of Tuberculosis and Chest Diseases, National Institute of Tuberculosis and Respiratory Diseases, New Delhi.
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Guo J, Han Y, Zhang X, Lin F, Chen L, Feng X. Risk factors of adult isoniazid-resistant and rifampicin-susceptible tuberculosis in Nanjing, 2019-2021. BMC Infect Dis 2024; 24:511. [PMID: 38773443 PMCID: PMC11110291 DOI: 10.1186/s12879-024-09404-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 05/13/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION This study aimed to analyze the risk factors associated with isoniazid-resistant and rifampicin-susceptible tuberculosis (Hr-TB) in adults. METHOD The clinical data of 1,844 adult inpatients diagnosed with culture-positive pulmonary tuberculosis (PTB) in Nanjing Second Hospital from January 2019 and December 2021 were collected. All culture positive strain from the patient specimens underwent drug susceptibility testing (DST). Among them, 166 patients with Hr-TB were categorized as the Hr-TB group, while the remaining 1,678 patients were classified as having drug-susceptible tuberculosis (DS-TB). Hierarchical logistic regression was employed for multivariate analysis to identify variables associated with Hr-TB. RESULTS Multivariate logistic regression analysis revealed that individuals with diabetes mellitus (DM) (OR 1.472, 95% CI 1.037-2.088, p = 0.030) and a history of previous tuberculosis treatment (OR 2.913, 95% CI 1.971-4.306, p = 0.000) were at higher risk of developing adult Hr-TB, with this risk being more pronounced in male patients. Within the cohort, 1,640 patients were newly treated, and among them, DM (OR 1.662, 95% CI 1.123-2.461, p = 0.011) was identified as risk factors for Hr-TB. CONCLUSIONS Diabetes mellitus is a risk factor for Hr-TB in adults, and the contribution of diabetes as a risk factor was more pronounced in the newly treatment or male subgroup. And previous TB treatment history is also a risk factor for Hr-TB in adults.
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Affiliation(s)
- Jing Guo
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
- Department of Tuberculosis, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 211132, China
| | - Yan Han
- Department of Tuberculosis, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 211132, China
| | - Xia Zhang
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
| | - Feishen Lin
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
| | - Liangyu Chen
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
| | - Xuebing Feng
- Department of Tuberculosis, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 211132, China.
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Al-Bari MAA, Peake N, Eid N. Tuberculosis-diabetes comorbidities: Mechanistic insights for clinical considerations and treatment challenges. World J Diabetes 2024; 15:853-866. [PMID: 38766427 PMCID: PMC11099355 DOI: 10.4239/wjd.v15.i5.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/08/2024] [Accepted: 03/21/2024] [Indexed: 05/10/2024] Open
Abstract
Tuberculosis (TB) remains a leading cause of death among infectious diseases, particularly in poor countries. Viral infections, multidrug-resistant and ex-tensively drug-resistant TB strains, as well as the coexistence of chronic illnesses such as diabetes mellitus (DM) greatly aggravate TB morbidity and mortality. DM [particularly type 2 DM (T2DM)] and TB have converged making their control even more challenging. Two contemporary global epidemics, TB-DM behaves like a syndemic, a synergistic confluence of two highly prevalent diseases. T2DM is a risk factor for developing more severe forms of multi-drug resistant-TB and TB recurrence after preventive treatment. Since a bidirectional relationship exists between TB and DM, it is necessary to concurrently treat both, and promote recommendations for the joint management of both diseases. There are also some drug-drug interactions resulting in adverse treatment outcomes in TB-DM patients including treatment failure, and reinfection. In addition, autophagy may play a role in these comorbidities. Therefore, the TB-DM comorbidities present several health challenges, requiring a focus on multidisciplinary collaboration and integrated strategies, to effectively deal with this double burden. To effectively manage the comorbidity, further screening in affected countries, more suitable drugs, and better treatment strategies are required.
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Affiliation(s)
| | - Nicholas Peake
- Biosciences and Chemistry and Biomolecular Research Centre, Sheffield Hallam University, Sheffield S1 1WB, United Kingdom
| | - Nabil Eid
- Department of Anatomy, Division of Human Biology, School of Medicine, International Medical University, Kuala Lumpur 57000, Malaysia
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Sales CA, Pinto-Silva MCF, Bardález-Rivera JG, Abreu-Alberio CA, Sena LWP, Vieira JLF. Level function levels and oxidative stress markers in patients with multidrug-resistant tuberculosis in the Brazilian Amazon. BRAZ J BIOL 2024; 83:e272512. [PMID: 38422258 DOI: 10.1590/1519-6984.272512] [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: 03/01/2023] [Accepted: 12/01/2023] [Indexed: 03/02/2024] Open
Abstract
This study aimed to correlate the values of liver markers with oxidative stress markers in patients with multidrug-resistant tuberculosis in the Brazilian Amazon. A total of 30 patients from the Tuberculosis clinic of a referral hospital were admitted to the study. Whole blood samples were collected for analysis of liver enzyme values and oxidative stress markers by spectrophotometry. The prevalence was male (60%) and the 18-29 age group was the most affected. Patients with multidrug-resistant tuberculosis presented catalase values with a median equal to 6.94 U/gHb and for glutathione, the median was equal to 14.76 µg∕ml. As for the values of liver enzymes (AST, ALT, Gamma-GT and Alkaline phosphatase) the patients had medians equal to 60.50 (U/L); 80 (U/L); 54 (U/L); and 100 (U/L) respectively (p<0.0001). The results suggest a hepatotoxic effect of the drug, which recommends further studies with a larger number of samples in order to investigate the predictors of liver damage in patients with multidrug-resistant tuberculosis.
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Affiliation(s)
- C A Sales
- Universidade Federal do Pará, Faculdade de Farmácia, Laboratório de Toxicologia, Belém, PA, Brasil
| | - M C F Pinto-Silva
- Universidade Federal do Pará, Faculdade de Farmácia, Laboratório de Toxicologia, Belém, PA, Brasil
| | - J G Bardález-Rivera
- Universidade Federal do Pará, Faculdade de Farmácia, Laboratório de Toxicologia, Belém, PA, Brasil
| | - C A Abreu-Alberio
- Universidade Federal do Pará, Faculdade de Farmácia, Laboratório de Toxicologia, Belém, PA, Brasil
| | - L W P Sena
- Universidade Federal do Sul e Sudeste do Pará, Faculdade de Saúde Pública, Marabá, PA, Brasil
| | - J L F Vieira
- Universidade Federal do Pará, Faculdade de Farmácia, Laboratório de Toxicologia, Belém, PA, Brasil
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Peng YF. Pulmonary tuberculosis and diabetes mellitus: Epidemiology, pathogenesis and therapeutic management (Review). MEDICINE INTERNATIONAL 2024; 4:4. [PMID: 38204892 PMCID: PMC10777470 DOI: 10.3892/mi.2023.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 11/22/2023] [Indexed: 01/12/2024]
Abstract
The dual burden of pulmonary tuberculosis (PTB) and diabetes mellitus (DM) is a major global public health concern. There is increasing evidence to indicate an association between PTB and DM. DM is associated with immune dysfunction and altered immune components. Hyperglycemia weakens the innate immune response by affecting the function of macrophages, dendritic cells, neutrophils, and natural killer cells, and also disrupts the adaptive immune response, thus promoting the susceptibility of PTB in patients with DM. Antituberculosis drugs often cause the impairment of liver and kidney function in patients with PTB, and the infection with Mycobacterium tuberculosis weaken pancreatic endocrine function by causing islet cell amyloidosis, which disrupts glucose metabolism and thus increases the risk of developing DM in patients with PTB. The present review discusses the association between PTB and DM from the perspective of epidemiology, pathogenesis, and treatment management. The present review aims to provide information for the rational formulation of treatment strategies for patients with PTB-DM.
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Affiliation(s)
- You-Fan Peng
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi 533000, P.R. China
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Kwak SH, Jeong D, Mok J, Jeon D, Kang HY, Kim HJ, Kim HS, Choi H, Kang YA. Association between diabetes mellitus and cause of death in patients with tuberculosis: A Korean nationwide cohort study. PLoS One 2023; 18:e0295556. [PMID: 38096233 PMCID: PMC10721100 DOI: 10.1371/journal.pone.0295556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/24/2023] [Indexed: 12/17/2023] Open
Abstract
Despite its significant impact on mortality, tuberculosis (TB)-diabetes mellitus (DM) co-prevalence has not been well-elucidated for the cause of death. We investigated the impact of DM on TB-related and non-TB-related deaths in patients with TB. This retrospective nationwide cohort study included patients diagnosed with TB between 2011 and 2017 in South Korea. We performed Fine and Gray regression model analyses to assess the mortality risk of DM classified by cause of death. Of 239,848 patients, 62,435 (26.0%) had DM, and 20,203 died during anti-TB treatment. Of all deaths, 47.9% (9,668) were caused by TB, and the remaining 52.1% (10,535) was attributed to various non-TB-related causes. The mortality rate was higher in the DM than in the non-DM groups in both men and women. DM was associated with a higher risk of TB-related (adjusted hazard ratio [aHR] 1.07, 95% confidence interval [CI] 1.01-1.13) and non-TB-related (aHR 1.21, 95% CI 1.15-1.27) deaths in men; however, only a higher risk of non-TB-related deaths (aHR 1.29, 95% CI 1.20-1.38) in women. Our findings indicate that DM is independently associated with a greater risk of death during anti-TB treatment among patients with TB for both TB-related and non-TB-related deaths.
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Affiliation(s)
- Se Hyun Kwak
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Dawoon Jeong
- Department of Preventive Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hee-Yeon Kang
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea
| | - Hee Jin Kim
- Jeju double cross clinic, Korean National Tuberculosis Association, Jeju, Republic of Korea
| | - Hee-Sun Kim
- Department of Health Policy Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Hongjo Choi
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
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D Freire I, L Fielding K, A J Moore D. Does diabetes mellitus comorbidity increase the risk of drug-induced liver injury during tuberculosis treatment? PLoS One 2023; 18:e0286306. [PMID: 37256882 DOI: 10.1371/journal.pone.0286306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 05/13/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The growing burden of diabetes worldwide is a threat to tuberculosis (TB) control. Drug-induced liver injury (DILI) due to TB drugs is a significant concern and there is currently limited evidence on the effect of diabetes on TB DILI. This study sought to investigate the effect of diabetes as a risk factor for DILI and to further study any potential co-factors. METHODS An unmatched case-control study. Cases were TB patients on 2RHZE/4RH presenting with DILI from 2013-2017 in Porto Alegre, Brazil. Controls were contemporaneous TB patients without DILI being treated in any one of the same five Porto Alegre TB clinics. The exposure variables were diabetes (main exposure variable), age, sex, alcohol misuse, human immunodeficiency virus (HIV), hepatitis C (HCV) and B (HBV) viruses, concomitant hepatotoxic drugs, other liver diseases and TB site. The outcome variable was the occurrence of DILI. RESULTS Odds of DILI were increased by: older age group 51-60, 61-70 and 71-93 years (adjusted OR 2.39, 95%CI 1.30-4,38; adjusted OR 4.37, 2.28-8,35; adjusted OR 12.91, 5.81-28,66, respectively), HIV positive status (adjusted OR 3.59, 95%CI 2.25-5.73), HCV positive status (adjusted OR 3.49, 95%CI 1.96-6.21) and having concurrent pulmonary and extrapulmonary TB (adjusted OR 3.16, 95%CI 1.93-5.19). Diabetes, gender, and other hepatotoxic drugs were not associated with DILI. CONCLUSIONS This study confirms the association between TB DILI and well-known risk factors but did not demonstrate increased odds of TB DILI in patients with diabetes.
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Affiliation(s)
- Ivanice D Freire
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David A J Moore
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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11
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Alkabab Y, Warkentin J, Cummins J, Katz B, Denison BM, Bartok A, Khalil A, Young LR, Timme E, Peloquin CA, Ashkin D, Houpt ER, Heysell SK. Therapeutic drug monitoring and TB treatment outcomes in patients with diabetes mellitus. Int J Tuberc Lung Dis 2023; 27:135-139. [PMID: 36853114 PMCID: PMC9904402 DOI: 10.5588/ijtld.22.0448] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/19/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND: Diabetes mellitus (DM) increases the risk of TB disease and poor treatment outcomes such as delayed sputum culture conversion due to inadequate drug exposure. Therapeutic drug monitoring (TDM) has improved these outcomes in some settings.METHODS: To compare treatment outcomes in programs with routine TDM vs. programs that did not use TDM, we conducted a retrospective study among people with DM and TB at health departments in four US states.RESULTS: A total of 170 patients were enrolled (73 patients in the non-TDM group and 97 patients in the TDM group). Days to sputum culture conversion and total treatment duration were significantly shorter in the TDM group vs. the non-TDM group. In adjusted analyses, patients who underwent TDM were significantly more likely to achieve sputum culture conversion at 2 months (P = 0.007).CONCLUSION: TDM hastened microbiological cure from TB among people with DM and a high risk for poor treatment outcomes in the programmatic setting.
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Affiliation(s)
- Y Alkabab
- Medical University of South Carolina, Charleston, SC, USA
| | - J Warkentin
- Tennessee Department of Health, Nashville, TN, USA
| | - J Cummins
- Tennessee Department of Health, Nashville, TN, USA
| | - B Katz
- Tennessee Department of Health, Nashville, TN, USA
| | - B M Denison
- New Mexico Department of Health, Santa Fe, NM, USA
| | - A Bartok
- New Mexico Department of Health, Santa Fe, NM, USA
| | - A Khalil
- Virginia Department of Health, Richmond, VA, USA
| | - L R Young
- Virginia Department of Health, Richmond, VA, USA
| | - E Timme
- Arizona Department of Health Services, Phoenix, AZ, USA
| | | | - D Ashkin
- University of Florida, Gainesville, FL, USA
| | - E R Houpt
- University of Virginia, Charlottesville, VA, USA
| | - S K Heysell
- University of Virginia, Charlottesville, VA, USA
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12
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Impact of diabetes mellitus on rifampicin's plasma concentration and bioavailability in patients with tuberculosis: A systematic review and meta-analysis study. Therapie 2022; 78:313-324. [DOI: 10.1016/j.therap.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/27/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022]
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13
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Pérez-Martínez DE, Bermúdez-Hernández GA, Madrazo-Moya CF, Cancino-Muñoz I, Montero H, Licona-Cassani C, Muñiz-Salazar R, Comas I, Zenteno-Cuevas R. SNPs in Genes Related to DNA Damage Repair in Mycobacterium Tuberculosis: Their Association with Type 2 Diabetes Mellitus and Drug Resistance. Genes (Basel) 2022; 13:genes13040609. [PMID: 35456415 PMCID: PMC9029044 DOI: 10.3390/genes13040609] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/19/2022] [Accepted: 03/24/2022] [Indexed: 12/04/2022] Open
Abstract
Genes related to DNA damage repair in Mycobacterium tuberculosis are critical for survival and genomic diversification. The aim of this study is to compare the presence of SNPs in genes related to DNA damage repair in sensitive and drug-resistant M. tuberculosis genomes isolated from patients with and without type 2 diabetes mellitus (T2DM). We collected 399 M. tuberculosis L4 genomes from several public repositories; 224 genomes belonging to hosts without T2DM, of which 123 (54.9%) had drug sensitive tuberculosis (TB) and 101 (45.1%) had drug resistance (DR)-TB; and 175 genomes from individuals with T2DM, of which 100 (57.1%) had drug sensitive TB and 75 (42.9%) had DR-TB. The presence of SNPs in the coding regions of 65 genes related to DNA damage repair was analyzed and compared with the resistance profile and the presence/absence of T2DM in the host. The results show the phylogenetic relationships of some SNPS and L4 sub-lineages, as well as differences in the distribution of SNPs present in DNA damage repair-related genes related to the resistance profile of the infecting strain and the presence of T2DM in the host. Given these differences, it was possible to generate two discriminant functions to distinguish between drug sensitive and drug resistant genomes, as well as patients with or without T2DM.
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Affiliation(s)
- Damián E. Pérez-Martínez
- Programa de Doctorado en Ciencias de la Salud, Instituto de Ciencias de la Salud, Universidad Veracruzana, Av. Luis, Dr. Castelazo Ayala s/n, Col. Industrial Animas, Xalapa 91190, Mexico; (D.E.P.-M.); (G.A.B.-H.)
| | - Gustavo A. Bermúdez-Hernández
- Programa de Doctorado en Ciencias de la Salud, Instituto de Ciencias de la Salud, Universidad Veracruzana, Av. Luis, Dr. Castelazo Ayala s/n, Col. Industrial Animas, Xalapa 91190, Mexico; (D.E.P.-M.); (G.A.B.-H.)
| | - Carlos F. Madrazo-Moya
- Biomedical Institute of Valencia IBV-CSIC, C. de Jaume Roig, 11, 46010 Valencia, Spain; (C.F.M.-M.); (I.C.-M.); (I.C.)
| | - Irving Cancino-Muñoz
- Biomedical Institute of Valencia IBV-CSIC, C. de Jaume Roig, 11, 46010 Valencia, Spain; (C.F.M.-M.); (I.C.-M.); (I.C.)
- CIBER of Epidemiology and Public Health, 08908 Madrid, Spain
| | - Hilda Montero
- Instituto de Salud Pública, Universidad Veracruzana, Av. Luis Castelazo Ayala s/n, A.P. 57, Col. Industrial Animas, Xalapa 91190, Mexico;
| | - Cuauhtemoc Licona-Cassani
- Escuela de Ingeniería y Ciencias, Tecnológico de Monterrey, Ave. Eugenio Garza Sada 2501 Sur, Monterrey 64849, Mexico;
- Red Multidisciplinaria de Investigación en Tuberculosis, Mexico City 14080, Mexico;
- Division of Integrative Biology, The Institute for Obesity Research, Tecnológico de Monterrey, Monterrey 64849, Mexico
| | - Raquel Muñiz-Salazar
- Red Multidisciplinaria de Investigación en Tuberculosis, Mexico City 14080, Mexico;
- Laboratorio de Epidemiología y Ecología Molecular, Escuela de Ciencias de la Salud, Universidad Autónoma de Baja California, Ensenada 22890, Mexico
| | - Iñaki Comas
- Biomedical Institute of Valencia IBV-CSIC, C. de Jaume Roig, 11, 46010 Valencia, Spain; (C.F.M.-M.); (I.C.-M.); (I.C.)
- CIBER of Epidemiology and Public Health, 08908 Madrid, Spain
| | - Roberto Zenteno-Cuevas
- Instituto de Salud Pública, Universidad Veracruzana, Av. Luis Castelazo Ayala s/n, A.P. 57, Col. Industrial Animas, Xalapa 91190, Mexico;
- Red Multidisciplinaria de Investigación en Tuberculosis, Mexico City 14080, Mexico;
- Correspondence:
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14
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Cáceres G, Calderon R, Ugarte-Gil C. Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression. Ther Adv Infect Dis 2022; 9:20499361221095831. [PMID: 35646347 PMCID: PMC9130847 DOI: 10.1177/20499361221095831] [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: 12/18/2021] [Accepted: 04/03/2022] [Indexed: 11/23/2022] Open
Abstract
Tuberculosis is one of the leading causes of death worldwide, primarily affecting
low- and middle income countries and individuals with limited-resources within
fractured health care systems. Unfortunately, the COVID-19 pandemic has only
served to aggravate the already existing diagnostic gap, decreasing the number
of people who get diagnosed and thereby complete successful treatment. In
addition to this, comorbidities act as an external component that when added to
the TB management equation, renders it even more complex. Among the various
comorbidities that interact with TB disease, diabetes mellitus and depression
are two of the most prevalent among non-communicable diseases within the TB
population and merits a thoughtful consideration when the healthcare system
provides care for them. TB patients with diabetes mellitus (TB-DM) or depression
both have an increased risk of mortality, relapse and recurrence. Both of these
diseases when in presence of TB present a ‘vicious-circle-like’ mechanism,
meaning that the effect of each disease can negatively add up, in a synergistic
manner, complicating the patient’s health state. Among TB-DM patients, high
glucose blood levels can decrease the effectiveness of anti-tuberculosis drugs;
however, higher doses of anti-tuberculous drugs could potentially decrease the
effects of DM drugs. Among the TB-depression patients, not only do we have the
adherence to treatment problems, but depression itself can biologically shift
the immunological profile responsible for TB containment, and the other way
around, TB itself can alter the hormonal balance of several neurotransmitters
responsible for depression. In this paper, we review these and other important
aspects such as the pharmacological interactions found in the treatment of TB-DM
and TB-depression patients and the implication on TB care and pharmacological
considerations.
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Affiliation(s)
- Guillermo Cáceres
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Rodrigo Calderon
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Cesar Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430-San Martin de Porres, Lima, Perú
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15
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LC-MS/MS method for simultaneous quantification of the first-line anti-tuberculosis drugs and six primary metabolites in patient plasma: Implications for therapeutic drug monitoring. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1185:122986. [PMID: 34688197 DOI: 10.1016/j.jchromb.2021.122986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 11/20/2022]
Abstract
The pharmacokinetic profiling of drug substances and corresponding metabolites in the biological matrix is one of the most informative tools for the treatment efficacy assessment. Therefore, to satisfy the need for comprehensive monitoring of anti-tuberculosis drugs in human plasma, a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated for simultaneous quantification of first-line anti-tuberculosis drugs (ethambutol, isoniazid, pyrazinamide, and rifampicin) along with their six primary metabolites. Simple single-step protein precipitation with methanol was chosen as the most convenient sample pre-treatment method. Chromatographic separation of the ten analyte mixture was achieved within 10 minutes on a reverse-phase C8 column using mobile phase gradient mode. The multiple reaction monitoring mode (MRM) was used for analyte detection and quantification in patient samples. The chosen quantification ranges fully covered expected plasma concentrations. The method exhibited acceptable selectivity; the within- and between-run accuracy ranged from 87.2 to 113.6%, but within- and between-run precision was between 1.6 and 14.9% (at the LLOQ level CV < 20%). Although the response of the isonicotinic acid varied depending on the matrix source (CV 21.8%), validation results proved that such inconsistency does not affect the accuracy and precision of results. If stored at room temperature plasma samples should be processed within 4 h after collection, temporary storage at -20 °C up to 24 h is acceptable due to stability issues of analytes. The developed method was applied for the patient sample analysis (n = 34) receiving anti-tuberculosis treatment with the first-line drugs.
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16
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Rajaa S, Krishnamoorthy Y, Knudsen S, Roy G, Ellner J, Horsburgh CR, Hochberg NS, Salgame P, S G, Prakash Babu S, Sarkar S. Prevalence and factors associated with diabetes mellitus among tuberculosis patients in South India-a cross-sectional analytical study. BMJ Open 2021; 11:e050542. [PMID: 34686553 PMCID: PMC8543642 DOI: 10.1136/bmjopen-2021-050542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the prevalence and determinants of diabetes mellitus (DM) among tuberculosis (TB) patients and to assess the additional yield and number needed to screen (NNS) to obtain a newly diagnosed DM among TB patients. DESIGN We undertook a cross-sectional analysis of the cohort data under Regional Prospective Observational Research for Tuberculosis-India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included. Pretested standardised questionnaires and tools were used for data collection. Prevalence of DM among TB patients was summarised as proportion with 95% CI. Type II DM was diagnosed if random blood sugar level was >200 mg/dL or if the participant had a documented history of DM. NNS by blood glucose testing to diagnose one new DM case among TB patients was also calculated. SETTING Three districts of South India: Puducherry, Cuddalore and Villupuram SUBJECTS: Newly diagnosed sputum smear positive pulmonary TB patients aged ≥16 years RESULTS: In total, 1188 TB patients were included. Prevalence of DM among TB patients was 39% (95% CI: 36.2% to 41.8%). In unadjusted analysis, elderly TB, marital status, caste, gender, higher education level, household income and obesity had a significant association with DM. However, in adjusted analysis, only marital status (currently married aPR; 3.77 (95 CI: 2.20 to 6.49), widowed/separated/divorced aPR; 3.66 (95 CI: 1.96 to 6.83)) and body mass index category (normal weight aPR; 3.26 (95 CI: 2.55 to 4.16), overweight aPR; 3.86 (95 CI: 2.69 to 5.52), obesity aPR; 4.08 (95 CI: 2.81 to 5.94)) were found to be significant determinants. The number of TB patients needed to be screened to find a new DM case was 12. CONCLUSION We found that one in three TB patients had coexisting DM. The number of TB patients needed to be screened to obtain a newly diagnosed DM patients was also determined. The study supports and highlights the need of RNTCP's effort in bidirectional screening of TB and DM.
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Affiliation(s)
- Sathish Rajaa
- Jawaharlal Institute of Postgraduate Medical Education, Puducherry, India
| | | | - Selby Knudsen
- Department of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Gautam Roy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, Puducherry, India
| | - Jerrold Ellner
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Govindarajan S
- Directorate of Health Services, State TB cell, Puducherry, India
| | - Senbagavalli Prakash Babu
- Department of Preventive and Social Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, Puducherry, India
| | - Sonali Sarkar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, Puducherry, India
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17
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Kim HW, Shin AY, Ha JH, Ahn JH, Kang HS, Kim JS. Effect of serum isoniazid level on treatment outcomes among tuberculosis patients with slow response - A retrospective cohort study. J Infect Chemother 2021; 27:1555-1561. [PMID: 34238662 DOI: 10.1016/j.jiac.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/02/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In this study, we investigate the effects of low serum TB drug level on treatment outcome among TB patients with slow response in South Korea, where the prevalence of rapid acetylator is relatively high. METHODS Among the pulmonary TB patients whose treatment outcomes were reported between 2014 and 2018 at Incheon St. Mary hospital, those who underwent TDM because of delayed culture conversion or reversion were included. Primary outcome was microbiological failure defined as (1) positive sputum culture after 120 days of treatment, or (2) culture-confirmed relapse within one year after treatment completion. Patients with culture conversion within 120 days and no relapse were classified as the final conversion group. Clinical characteristics and serum drug concentration at 2 h after administration (C2hr) were compared between those two groups. RESULTS A total of 55 pulmonary TB patients were included. Prevalence of subtherapeutic range of C2hr for isoniazid and rifampin was 78.2% and 21.8%, respectively. With one year of follow-up, 21 cases were classified as the microbiological failure group, and 34 cases as the final conversion group. In a multivariable logistic regression model for predicting microbiological failure, C2hr of isoniazid was the most significant predictor after adjusting for the effects of age and sex (adjusted odds ratio, 0.29; p = 0.009). In a tree-based classification model, C2hr of isoniazid with cutoff level 2.5 μg/ml was the most important variable for predicting microbiological failure. CONCLUSIONS Low serum isoniazid level was related to poor treatment outcomes among the TB patients with slow response.
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Affiliation(s)
- Hyung Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ah Young Shin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jick Hwan Ha
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joong Hyun Ahn
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Seon Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Sang Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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18
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Ichikawa C, Tanaka S, Takubo M, Kushimoto M, Ikeda J, Ogawa K, Tsujino I, Suzuki Y, Abe M, Ishihara H, Fujishiro M. Tuberculosis Relapse in the Epididymis After the Completion of Nine Months of Anti-Tuberculosis Chemotherapy in a Patient with Poorly Controlled Diabetes Mellitus. Ther Clin Risk Manag 2021; 17:463-470. [PMID: 34079268 PMCID: PMC8164866 DOI: 10.2147/tcrm.s310463] [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: 03/10/2021] [Accepted: 05/09/2021] [Indexed: 11/25/2022] Open
Abstract
The standard six-month tuberculosis (TB) treatment comprises an intensive phase lasting two months, followed by a continuation phase lasting four months. Meanwhile, the nine-month regimen, which has a prolonged continuation phase, is indicated for patients with complicated diabetes mellitus (DM) because of their poor response to treatment. A 61-year-old Japanese man with poorly controlled DM for five years presented with bilateral scrotal swelling noticed two weeks ago. He had a history of pleuritis, pericarditis, and peritonitis two years ago. These symptoms led to the diagnosis of culture-negative extrapulmonary TB. He received the nine-month chemotherapy regimen (isoniazid, rifampin, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampin for seven months), and his symptoms significantly improved. The swollen scrotum was accompanied by mild tenderness and pus discharge from a fistula. Imaging study revealed bilaterally diffusely enlarged epididymis. However, the acid-fast bacilli smear and culture and polymerase chain reaction using urine and pus discharge tested negative. Bilateral epididymectomy was performed. Although the acid-fast bacilli smear was negative, the pathology demonstrated granuloma formation and acid-fast bacilli tissue culture confirmed multi-drug resistant Mycobacterium tuberculosis. The optimal treatment regimen and duration for extrapulmonary TB with unknown drug susceptibility are debatable. The nine-month regimen can be insufficient in some cases. Thus, detailed follow-up is essential, and TB relapse should be thoroughly monitored.
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Affiliation(s)
- Chikako Ichikawa
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sho Tanaka
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Masahiro Takubo
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Masaru Kushimoto
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Jin Ikeda
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Katsuhiko Ogawa
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ichiro Tsujino
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hisamitsu Ishihara
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Midori Fujishiro
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
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19
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Mtabho CM, Semvua HH, van den Boogaard J, Irongo CF, Boeree MJ, Colbers A, Burger DM, van Crevel R, van der Ven AJAM, Kibiki GS, Tostmann A, Aarnoutse RE. Effect of diabetes mellitus on TB drug concentrations in Tanzanian patients. J Antimicrob Chemother 2020; 74:3537-3545. [PMID: 31651031 PMCID: PMC7183353 DOI: 10.1093/jac/dkz368] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/05/2019] [Accepted: 07/25/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with poor TB treatment outcome. Previous studies examining the effect of DM on TB drug concentrations yielded conflicting results. No studies have been conducted to date in an African population. OBJECTIVES To compare exposure to TB drugs in Tanzanian TB patients with and without DM. PATIENTS AND METHODS A prospective pharmacokinetic study was performed among 20 diabetic and 20 non-diabetic Tanzanian TB patients during the intensive phase of TB treatment. Plasma pharmacokinetic parameters of isoniazid, rifampicin, pyrazinamide and ethambutol were compared using an independent-sample t-test on log-transformed data. Multiple linear regression analysis was performed to assess the effects of DM, gender, age, weight, HIV status and acetylator status on exposure to TB drugs. RESULTS A trend was shown for 25% lower total exposure (AUC0-24) to rifampicin among diabetics versus non-diabetics (29.9 versus 39.9 mg·h/L, P=0.052). The AUC0-24 and peak concentration (Cmax) of isoniazid were also lower in diabetic TB patients (5.4 versus 10.6 mg·h/L, P=0.015 and 1.6 versus 2.8 mg/L, P=0.013). Pyrazinamide AUC0-24 and Cmax values were non-significantly lower among diabetics (P=0.08 and 0.09). In multivariate analyses, DM remained an independent predictor of exposure to isoniazid and rifampicin, next to acetylator status for isoniazid. CONCLUSIONS There is a need for individualized dosing of isoniazid and rifampicin based on plasma concentration measurements (therapeutic drug monitoring) and for clinical trials on higher doses of these TB drugs in patients with TB and DM.
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Affiliation(s)
- Charles M Mtabho
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Hadija H Semvua
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jossy van den Boogaard
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Radboud university medical center, Department of Lung Diseases & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Constantine F Irongo
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,National Tuberculosis and Leprosy Programme, Kilimanjaro Region, Tanzania
| | - Martin J Boeree
- Radboud university medical center, Department of Lung Diseases & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Angela Colbers
- Radboud university medical center, Department of Pharmacy & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - David M Burger
- Radboud university medical center, Department of Pharmacy & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Radboud university medical center, Department of Internal Medicine & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Andre J A M van der Ven
- Radboud university medical center, Department of Internal Medicine & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gibson S Kibiki
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Alma Tostmann
- Radboud university medical center, Department of Lung Diseases & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Radboud university medical center, Department of Pharmacy & Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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20
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Kodiatte A, John M, Jacob JJ. Diabetes mellitus and prediabetes among patients with tuberculosis in a single north Indian tertiary care centre. J R Coll Physicians Edinb 2020; 50:242-246. [PMID: 32936096 DOI: 10.4997/jrcpe.2020.306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prevalence of diabetes mellitus (DM), though believed to be high among patients with tuberculosis (TB), remains unclear for the want of systematic studies and unequivocal methods of diagnosing DM. This study was done to determine the prevalence of prediabetes and DM in adult patients with TB. METHODS This prospective study of one year's duration, carried out at a tertiary care centre included 313 consecutive adult patients diagnosed (either microbiologically, histologically or based on clinical presentation) with pulmonary or extrapulmonary TB. Those without a history of pre-existing DM were subjected to oral glucose tolerance test (OGTT) with 75 g glucose. RESULTS In this cohort 85 (27%) patients had pre-existing DM. The remaining 228 patients not diagnosed earlier with DM underwent a 75 g OGTT, of which 63 (28%) were found to have newly detected prediabetes (impaired fasting glucose [IFG] and impaired glucose tolerance [IGT] alone in 36 and 10 patients respectively and both IFG and IGT in a further 17) and DM was diagnosed in 9 (4%) patients (fasting blood glucose [FBG] ˜ 126 mg/dl in 1 and both FBG ˜ 126 mg/dl and 2-h plasma blood glucose [PLBG] ˜ 200 mg/dl in 8 patients). The total prevalence of (newly diagnosed) DM and prediabetes, therefore, was 32% (72 patients); the overall prevalence of DM was 30% (94 patients). CONCLUSION This study found high prevalence of prediabetes and diabetes among patients with TB. This underscores the need for a bidirectional screening strategy to improve diagnosis and outcome of both TB and DM.
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Affiliation(s)
- Abraham Kodiatte
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mary John
- Department of Endocrinology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Jubbin Jagan Jacob
- Department of Endocrinology, Christian Medical College and Hospital, Ludhiana, Punjab, India,
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Abulfathi AA, Decloedt EH, Svensson EM, Diacon AH, Donald P, Reuter H. Clinical Pharmacokinetics and Pharmacodynamics of Rifampicin in Human Tuberculosis. Clin Pharmacokinet 2020; 58:1103-1129. [PMID: 31049868 DOI: 10.1007/s40262-019-00764-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The introduction of rifampicin (rifampin) into tuberculosis (TB) treatment five decades ago was critical for shortening the treatment duration for patients with pulmonary TB to 6 months when combined with pyrazinamide in the first 2 months. Resistance or hypersensitivity to rifampicin effectively condemns a patient to prolonged, less effective, more toxic, and expensive regimens. Because of cost and fears of toxicity, rifampicin was introduced at an oral daily dose of 600 mg (8-12 mg/kg body weight). At this dose, clinical trials in 1970s found cure rates of ≥ 95% and relapse rates of < 5%. However, recent papers report lower cure rates that might be the consequence of increased emergence of resistance. Several lines of evidence suggest that higher rifampicin doses, if tolerated and safe, could shorten treatment duration even further. We conducted a narrative review of rifampicin pharmacokinetics and pharmacodynamics in adults across a range of doses and highlight variables that influence its pharmacokinetics/pharmacodynamics. Rifampicin exposure has considerable inter- and intra-individual variability that could be reduced by administration during fasting. Several factors including malnutrition, HIV infection, diabetes mellitus, dose size, pharmacogenetic polymorphisms, hepatic cirrhosis, and substandard medicinal products alter rifampicin exposure and/or efficacy. Renal impairment has no influence on rifampicin pharmacokinetics when dosed at 600 mg. Rifampicin maximum (peak) concentration (Cmax) > 8.2 μg/mL is an independent predictor of sterilizing activity and therapeutic drug monitoring at 2, 4, and 6 h post-dose may aid in optimizing dosing to achieve the recommended rifampicin concentration of ≥ 8 µg/mL. A higher rifampicin Cmax is required for severe forms TB such as TB meningitis, with Cmax ≥ 22 μg/mL and area under the concentration-time curve (AUC) from time zero to 6 h (AUC6) ≥ 70 μg·h/mL associated with reduced mortality. More studies are needed to confirm whether doses achieving exposures higher than the current standard dosage could translate into faster sputum conversion, higher cure rates, lower relapse rates, and less mortality. It is encouraging that daily rifampicin doses up to 35 mg/kg were found to be safe and well-tolerated over a period of 12 weeks. High-dose rifampicin should thus be considered in future studies when constructing potentially shorter regimens. The studies should be adequately powered to determine treatment outcomes and should include surrogate markers of efficacy such as Cmax/MIC (minimum inhibitory concentration) and AUC/MIC.
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Affiliation(s)
- Ahmed Aliyu Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Andreas H Diacon
- Task Applied Science, Bellville, South Africa.,Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Donald
- Paediatrics and Child Health and Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helmuth Reuter
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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Fonseca AAD, Pinto ACG, Paixão TPD, Albério CAA, Vieira JLF. Can diabetes mellitus modify the plasma concentrations of rifampicin in patients under treatment for tuberculosis? Braz J Infect Dis 2020; 24:352-355. [PMID: 32535111 PMCID: PMC9392073 DOI: 10.1016/j.bjid.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022] Open
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Lyu M, Wang D, Zhao J, Yang Z, Chong W, Zhao Z, Ming L, Ying B. A novel risk factor for predicting anti-tuberculosis drug resistance in patients with tuberculosis complicated with type 2 diabetes mellitus. Int J Infect Dis 2020; 97:69-77. [PMID: 32474202 DOI: 10.1016/j.ijid.2020.05.080] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES This study aimed to explore the relationship between glycosylated hemoglobin (HbA1c) and the risk of anti-tuberculosis (TB) drug resistance for TB-type 2 diabetes mellitus (T2DM) patients. METHODS From March 2014 to June 2019, medical records from multiple centers were searched. Logistic regression analyses were performed. A predictive model for multidrug-resistance (MDR) was developed and validated. Calibration and discrimination of the model were assessed. RESULTS Inconsistent results were found in the systemic review. A multicenter chart review with 657 records was thus conducted. The HbA1c <7% group and HbA1c ≥7% group had 390 and 267 patients, respectively. The HbA1c<7% group had a lower risk of developing rifampicin resistance, isoniazid resistance and MDR, with odd ratios (ORs) of 1.904 (p=0.001), 2.896 (p<0.001) and 3.228 (p<0.001), respectively. The between-group differences in the risk of anti-TB drug resistance were analyzed based on data from three provinces in China. After adding HbA1c grading, the predictive model for MDR (https://mengyuan.shinyapps.io/Shinyapp/) showed excellent capacity with an AUC of 75.4% in the training set (Sichuan and Gansu) and 73.9% in the internal validation set (Henan). The performances in calibration, prediction probabilities and net clinical benefit were significantly improved by HbA1c grading. CONCLUSIONS HbA1c grading was an independent risk factor for isoniazid resistance and MDR in TB-T2DM patients.
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Affiliation(s)
- Mengyuan Lyu
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Dongmei Wang
- Department of Clinical Laboratory, Public Health Clinical Center of Chengdu, Sichuan, China
| | - Junwei Zhao
- Clinical Laboratory, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zengwei Yang
- Clinical Laboratory, the Pulmonary Hospital of Lanzhou, Lanzhou, Gansu, China
| | - Weelic Chong
- Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Zhenzhen Zhao
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Liang Ming
- Clinical Laboratory, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China.
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Yang Y, Liu X. Imbalance of Drug Transporter-CYP450s Interplay by Diabetes and Its Clinical Significance. Pharmaceutics 2020; 12:E348. [PMID: 32290519 PMCID: PMC7238081 DOI: 10.3390/pharmaceutics12040348] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 02/07/2023] Open
Abstract
The pharmacokinetics of a drug is dependent upon the coordinate work of influx transporters, enzymes and efflux transporters (i.e., transporter-enzyme interplay). The transporter-enzyme interplay may occur in liver, kidney and intestine. The influx transporters involving drug transport are organic anion transporting polypeptides (OATPs), peptide transporters (PepTs), organic anion transporters (OATs), monocarboxylate transporters (MCTs) and organic cation transporters (OCTs). The efflux transporters are P-glycoprotein (P-gp), multidrug/toxin extrusions (MATEs), multidrug resistance-associated proteins (MRPs) and breast cancer resistance protein (BCRP). The enzymes related to drug metabolism are mainly cytochrome P450 enzymes (CYP450s) and UDP-glucuronosyltransferases (UGTs). Accumulating evidence has demonstrated that diabetes alters the expression and functions of CYP450s and transporters in a different manner, disordering the transporter-enzyme interplay, in turn affecting the pharmacokinetics of some drugs. We aimed to focus on (1) the imbalance of transporter-CYP450 interplay in the liver, intestine and kidney due to altered expressions of influx transporters (OATPs, OCTs, OATs, PepTs and MCT6), efflux transporters (P-gp, BCRP and MRP2) and CYP450s (CYP3As, CYP1A2, CYP2E1 and CYP2Cs) under diabetic status; (2) the net contributions of these alterations in the expression and functions of transporters and CYP450s to drug disposition, therapeutic efficacy and drug toxicity; (3) application of a physiologically-based pharmacokinetic model in transporter-enzyme interplay.
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Affiliation(s)
| | - Xiaodong Liu
- Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing 210009, China;
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Sundell J, Bienvenu E, Janzén D, Birgersson S, Äbelö A, Ashton M. Model-Based Assessment of Variability in Isoniazid Pharmacokinetics and Metabolism in Patients Co-Infected With Tuberculosis and HIV: Implications for a Novel Dosing Strategy. Clin Pharmacol Ther 2020; 108:73-80. [PMID: 32017035 DOI: 10.1002/cpt.1806] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
Tuberculosis is the most common cause of death in HIV-infected patients. Isoniazid is used as a first-line drug to treat tuberculosis infection. However, variability in isoniazid pharmacokinetics can result in hepatotoxicity or treatment failure. Determination of clinical factors affecting isoniazid pharmacokinetics and metabolic pathways in HIV co-infected patients is therefore critical. Plasma levels of isoniazid, acetyl-isoniazid, and isonicotinic acid from 63 patients co-infected with tuberculosis and HIV were analyzed by liquid chromatography with tandem mass spectrometry followed by nonlinear mixed-effects modeling. Patients were genotyped to determine acetylator status. Patients were either on concomitant efavirenz-based antiretroviral therapy or HIV treatment naïve. Clearances of isoniazid were 1.3-fold and 2.3-fold higher in intermediate and rapid acetylators, respectively, compared with slow acetylators. Patients on concomitant efavirenz-based antiretroviral therapy had 64% and 80% higher population predicted clearances of acetyl-isoniazid and isonicotinic acid, respectively, compared with patients who were HIV treatment naïve. Both sex and CD4 cell count affected the bioavailability of isoniazid. Variability in isoniazid exposure could be reduced by dose adaptions based on acetylator type and sex in addition to the currently used weight bands. A novel dosing strategy that has the potential to reduce isoniazid-related toxicity and treatment failure is presented.
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Affiliation(s)
- Jesper Sundell
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Emile Bienvenu
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - David Janzén
- Drug Metabolism and Pharmacokinetics, Early Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Sofia Birgersson
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Angela Äbelö
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Michael Ashton
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Anthropometric and Genetic Factors Associated With the Exposure of Rifampicin and Isoniazid in Mexican Patients With Tuberculosis. Ther Drug Monit 2019; 41:648-656. [DOI: 10.1097/ftd.0000000000000631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dekkers BG, Bolhuis MS, ter Beek L, de Lange WC, van der Werf TS, Alffenaar JWC, Akkerman OW. Reduced moxifloxacin exposure in patients with tuberculosis and diabetes. Eur Respir J 2019; 54:13993003.00373-2019. [DOI: 10.1183/13993003.00373-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/20/2019] [Indexed: 12/12/2022]
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Role of Therapeutic Drug Monitoring in Treatment Optimization in Tuberculosis and Diabetes Mellitus Comorbidity. Antimicrob Agents Chemother 2019; 63:AAC.02074-18. [PMID: 30455234 DOI: 10.1128/aac.02074-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chirehwa MT, McIlleron H, Wiesner L, Affolabi D, Bah-Sow O, Merle C, Denti P. Effect of efavirenz-based antiretroviral therapy and high-dose rifampicin on the pharmacokinetics of isoniazid and acetyl-isoniazid. J Antimicrob Chemother 2019; 74:139-148. [PMID: 30239829 PMCID: PMC6293084 DOI: 10.1093/jac/dky378] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/17/2018] [Accepted: 08/24/2018] [Indexed: 02/03/2023] Open
Abstract
Objectives To describe the pharmacokinetics of isoniazid and acetyl-isoniazid in TB/HIV-coinfected patients, and assess the effects of efavirenz co-administration and a 50% increase in the dose of rifampicin on the pharmacokinetic parameters of isoniazid and acetyl-isoniazid. Methods TB/HIV-coinfected patients participating in the three-treatment-arm RAFA randomized controlled trial conducted in West Africa were recruited into the pharmacokinetics sub-study. Five serial blood samples were collected on a single visit between 4 and 8 weeks after initiation of antituberculosis treatment. Concentration-time data for isoniazid and acetyl-isoniazid were analysed using non-linear mixed-effects models. Results Isoniazid concentrations from 150 patients were available for analysis, and 79 of these (53%) also had concentrations of acetyl-isoniazid. Isoniazid pharmacokinetics was best described with a two-compartment disposition model with lagged first-order absorption and elimination using a semi-mechanistic model describing hepatic extraction. The model identified two elimination pathways, separating formation of acetyl-isoniazid from other routes of metabolism. The predicted AUC0-24 is reduced by 29% in patients who are fast acetylators of isoniazid and receiving efavirenz-based ART (6.73 versus 4.68 mg·h/L). In slow acetylators, efavirenz-based ART had no effect on isoniazid exposure (AUC0-24 = 17.5 mg·h/L). Conclusions Efavirenz-based ART affects the acetylation metabolic pathway amongst rapid acetylators, resulting in reduced exposure to isoniazid. Pharmacokinetics of isoniazid and acetyl-isoniazid were not influenced by the 50% increase in rifampicin dose.
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Affiliation(s)
- Maxwell T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dissou Affolabi
- National Programme for Tuberculosis and Pulmonary Diseases, Cotonou, Benin
| | - Oumou Bah-Sow
- Service de Pneumo-Phtisiologie, Hopital Ignace Deen, Conakry, Guinea
| | - Corinne Merle
- London School of Hygiene & Tropical Medicine, London, UK
- UNICEF/UNDP/World Bank/WHO Special Programme on Research and Training in Tropical Diseases (TDR), Geneva, Switzerland
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Effect of Diabetes Mellitus on the Pharmacokinetics and Pharmacodynamics of Tuberculosis Treatment. Antimicrob Agents Chemother 2018; 62:AAC.01383-18. [PMID: 30126955 DOI: 10.1128/aac.01383-18] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/09/2018] [Indexed: 01/03/2023] Open
Abstract
Diabetes mellitus (DM) and tuberculosis (TB) are two common diseases with increasing geographic overlap and clinical interactions. The effect of DM and hemoglobin A1c (HbA1c) values on the pharmacokinetics (PK) and pharmacodynamics (PD) of anti-TB drugs remains poorly characterized. Newly diagnosed TB patients with and without DM starting fixed-dose, thrice-weekly treatment underwent sampling for PK assessments (predose and 0.5, 2, and 6 h postdose) during the intensive and continuation phases of treatment. The effect of DM and HbA1c values on the maximum concentration (C max) of rifampin, isoniazid, and pyrazinamide and the association between drug concentrations and microbiologic and clinical outcomes were assessed. Of 243 patients, 101 had DM. Univariate analysis showed significant reductions in the C max of pyrazinamide and isoniazid (but not rifampin) with DM or increasing HbA1c values. After adjusting for age, sex, and weight, DM was associated only with reduced pyrazinamide concentrations (adjusted geometric mean ratio = 0.74, P = 0.03). In adjusted Cox models, female gender (adjusted hazards ratio [aHR] = 1.75, P = 0.001), a lower smear grade with the Xpert assay (aHR = 1.40, P < 0.001), and the pyrazinamide C max (aHR = 0.99, P = 0.006) were independent predictors of sputum culture conversion to negative. Higher isoniazid or rifampin concentrations were associated with a faster time to culture conversion in patients with DM only. A pyrazinamide C max above the therapeutic target was associated with higher unfavorable outcomes (treatment failure, relapse, death) (odds ratio = 1.92, P = 0.04). DM and higher HbA1c values increased the risk of not achieving therapeutic targets for pyrazinamide (but not rifampin or isoniazid). Higher pyrazinamide concentrations, though, were associated with worse microbiologic and clinical outcomes. DM status also appeared to influence PK-PD relationships for isoniazid and rifampin.
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Ahmad S, Mokaddas E, Al-Mutairi NM. Prevalence of tuberculosis and multidrug resistant tuberculosis in the Middle East Region. Expert Rev Anti Infect Ther 2018; 16:709-721. [PMID: 30173588 DOI: 10.1080/14787210.2018.1519393] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Prevalence of TB and MDR-TB varies considerably among various regions of World Health Organization (WHO) and also among individual countries within each region. Many Middle Eastern countries have war/civil war-like situations, refugees from war-torn countries or dynamic expatriate population from TB endemic countries which will likely affect the END-TB strategy launched by the WHO in 2015. Areas covered: The data for each of 17 countries comprising the Middle East were analyzed for estimated incidence of TB, number of notified TB cases, mortality rate, and rate of MDR-TB in new and previously treated TB cases as reported by WHO. Data from national surveys or surveillance studies from individual countries were also analyzed for incidence of MDR-TB in new and previously treated TB patients and compared with the estimated data by WHO. Expert commentary: Several Middle Eastern countries have low/intermediate incidence rate and are striving for TB elimination. Reaching pre-elimination (< 1 TB case per 100 000 population) stage will require testing and treatment of latent TB infection in groups at high risk of reactivation and effective treatment of drug-susceptible and drug-resistant TB cases. Large numbers of refugees, expatriate workers, or confounding noncommunicable diseases in some countries pose major challenges in achieving progress toward TB elimination.
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Affiliation(s)
- Suhail Ahmad
- a Department of Microbiology, Faculty of Medicine , Kuwait University , Jabriya , Kuwait
| | - Eiman Mokaddas
- a Department of Microbiology, Faculty of Medicine , Kuwait University , Jabriya , Kuwait
| | - Noura M Al-Mutairi
- a Department of Microbiology, Faculty of Medicine , Kuwait University , Jabriya , Kuwait
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Govender K, Adamson JH, Owira P. The development and validation of a LC-MS/MS method for the quantitation of metformin, rifampicin and isoniazid in rat plasma using HILIC chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1095:127-137. [DOI: 10.1016/j.jchromb.2018.07.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 07/27/2018] [Accepted: 07/29/2018] [Indexed: 12/27/2022]
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Xia LL, Li SF, Shao K, Zhang X, Huang S. The correlation between CT features and glycosylated hemoglobin level in patients with T2DM complicated with primary pulmonary tuberculosis. Infect Drug Resist 2018; 11:187-193. [PMID: 29430189 PMCID: PMC5796470 DOI: 10.2147/idr.s146741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
To investigate the correlation between computed tomography (CT) features and glycosylated hemoglobin (HbAlc) levels in patients with type 2 diabetes mellitus (T2DM) complicated with primary pulmonary tuberculosis (PTB). One hundred and eighty untreated PTB patients complicated with T2DM were selected. Based on the HbAlc level, the patients were divided into three groups: HbAlc level <7% (Group I: 32 patients), 7%–9% (Group II: 48 patients), and >9% (Group III: 100 patients). The changes of CT manifestations and HbAlc were analyzed after TB and T2DM treatment. In the three groups, the detection rate of large segmented leafy shadow was 50%, 56.2%, and 87%; the air bronchogram sign detection rate was 40.6%, 47.9%, and 77%; the discovery rate of mouth-eaten cavity was 31.2%, 45.8%, and 65%; thick wall cavity detection rate was 25%, 31.2%, and 52%; the rate of multiple cavities was 34.3%, 50%, and 73%; and bronchial TB was found in 33.3%, 21.8%, and 46%, respectively. The detection rates of lesions in Group III were significantly higher than in Group II and Group I (p<0.05), and this increase was significant (p<0.05). After treatment, the HbAlc level reached control target (<7%) among all three groups and CT absorption improvement rates were 100%, 72.9%, and 56% respectively. The therapeutic efficacy of group I was better than group II (p<0.01), and the treatment efficacy of group II was better than group III (p<0.05). CT manifestations of T2DM complicated with PTB were closely related to HbAlc level. The effect is better when HbAlc level <7%. HbAlc level effectively reflects the severity and therapeutic effect to a certain extent. CT scan can provide some important information for clinical imaging. The above two examinations can guide clinicians to formulate the appropriate diagnosis and treatment in a timely manner.
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Affiliation(s)
- Li-Li Xia
- Department of Endocrinology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Su-Fen Li
- Department of Neurology, Huai'an Second People's Hospital and The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, People's Republic of China
| | - Kan Shao
- Department of Endocrinology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xin Zhang
- Department of Radiology, The Fourth People's Hospital of Huai'an, Huai'an, People's Republic of China
| | - Shan Huang
- Department of Endocrinology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Alkabab YM, Enani MA, Indarkiri NY, Heysell SK. Performance of computed tomography versus chest radiography in patients with pulmonary tuberculosis with and without diabetes at a tertiary hospital in Riyadh, Saudi Arabia. Infect Drug Resist 2018; 11:37-43. [PMID: 29379307 PMCID: PMC5757200 DOI: 10.2147/idr.s151844] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Prior research suggests that diabetes mellitus (DM) is associated with increasing risk for developing cavitary lung disease in patients with pulmonary tuberculosis (TB). Additionally, chest computed tomography (CT) scan may be more sensitive than chest X-ray in detecting cavitary disease in such patients. The aim of this study was to compare the performance of chest CT to chest X-ray in detecting cavitary lung disease and to compare the frequency of cavities between TB patients with DM and without DM. Patients and methods We conducted a retrospective cohort study at King Fahad Medical City, Riyadh, Saudi Arabia, from January 2004 to December 2015. We included patients aged 18 years and older with a positive sputum culture for Mycobacterium tuberculosis, and their medical charts were reviewed from admission to discharge. Results Of the 133 patients who met the inclusion criteria, 38 (28.6%) patients were known to have DM and were compared with 95 (71.4%) patients without DM. DM patients with glycated hemoglobin (HbA1c) >6.5% had significantly more cavitary lesions when compared to all patients (with or without DM) with HbA1c <6.4% and/or random blood sugar <200 mg/dL. Furthermore, CT was able to detect lung cavities in 58.8% of the patients who had negative chest X-ray findings for cavities. Conclusion The presence of lung cavities was significantly associated with the presence of DM and levels of HbA1c in patients with pulmonary TB. CT scan in those with normal radiography increased the detection of cavities.
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Affiliation(s)
- Yosra M Alkabab
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | | | - Nouf Y Indarkiri
- Department of Family Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Scott K Heysell
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
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Motta I, Calcagno A, Bonora S. Pharmacokinetics and pharmacogenetics of anti-tubercular drugs: a tool for treatment optimization? Expert Opin Drug Metab Toxicol 2017; 14:59-82. [PMID: 29226732 DOI: 10.1080/17425255.2018.1416093] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION WHO global strategy is to end tuberculosis epidemic by 2035. Pharmacokinetic and pharmacogenetic studies are increasingly performed and might confirm their potential role in optimizing treatment outcome in specific settings and populations. Insufficient drug exposure seems to be a relevant factor in tuberculosis outcome and for the risk of phenotypic resistance. Areas covered: This review discusses available pharmacokinetic and pharmacogenetic data of first and second-line antitubercular agents in relation to efficacy and toxicity. Pharmacodynamic implications of optimized drugs and new options regimens are reviewed. Moreover a specific session describes innovative investigations on drug penetration. Expert opinion: The optimal use of available antitubercular drugs is paramount for tuberculosis control and eradication. Whilst trials are still on-going, higher rifampicin doses should be reserved to treatment for tubercular meningitis. Therapeutic Drug Monitoring with limiting sampling strategies is advised in patients at risk of failure or with slow treatment response. Further studies are needed in order to provide definitive recommendations of pharmacogenetic-based individualization: however lower isoniazid doses in NAT2 slow acetylators and higher rifampicin doses in individuals with SLCO1B1 loss of function genes are promising strategies. Finally in order to inform tailored strategies we need more data on tissue drug penetration and pharmacological modelling.
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Affiliation(s)
- Ilaria Motta
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
| | - Andrea Calcagno
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
| | - Stefano Bonora
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
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Yew WW, Leung CC, Zhang Y. Oxidative stress and TB outcomes in patients with diabetes mellitus? J Antimicrob Chemother 2017; 72:1552-1555. [PMID: 28204508 DOI: 10.1093/jac/dkx046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In patients with diabetes mellitus, TB treatment outcomes are poorer. Most parameters, when measured, reflect the slower bacteriological conversion from positivity to negativity and higher risks of disease relapse and mortality, as well as a greater propensity to develop drug-resistant TB. Aside from the well-known immunological dysfunction inherent to patients with diabetes mellitus, oxidative stress is likely a major underlying mechanism adversely impacting their TB treatment outcomes. Mycobacterium tuberculosis persisters, formed as a result of the core dormancy response to stress, possibly play a central role in this hypothesis. This hypothetical model also underscores the paramount importance of programmatic management of TB and diabetes mellitus, in collaboration, to improve the outcomes of patients with both diseases. The validity of these ideas could be further ascertained by laboratory and clinical research.
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Affiliation(s)
- Wing Wai Yew
- Stanley Ho Centre for Emerging Infectious Diseases, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi Chiu Leung
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong, China
| | - Ying Zhang
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Zheng C, Hu X, Zhao L, Hu M, Gao F. Clinical and pharmacological hallmarks of rifapentine's use in diabetes patients with active and latent tuberculosis: do we know enough? DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2957-2968. [PMID: 29066867 PMCID: PMC5644564 DOI: 10.2147/dddt.s146506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rifapentine is a rifamycin derivate approved by the US Food and Drug Administration in 1998 for the treatment of active, drug-susceptible tuberculosis (TB). In 2014, rifapentine was approved for the treatment of latent TB infection in patients at high risk of progression to active disease and is currently under evaluation by the European Medicines Agency. Expanding indications of rifapentine largely affect diabetes patients, since about one-third of them harbor latent TB. Clinical consequences of rifapentine use in this population and potentially harmful interactions with hypoglycemic agents are widely underexplored and generally considered similar to the ones of rifampicin. Indeed, rifapentine too may decrease blood levels of many oral antidiabetics and compete with them for protein-binding sites and/or transporters. However, the two drugs differ in protein-binding degree, the magnitude of cytochrome P450 induction and auto-induction, the degree of renal elimination, and so on. Rifapentine seems to be more suitable for use in diabetes patients with renal impairment, owing to the fact that it does not cause renal toxicity, and it is eliminated via kidneys in smaller proportions than rifampicin. On the other hand, there are no data related to rifapentine use in patients >65 years, and hypoalbuminemia associated with diabetic kidney disease may affect a free fraction of rifapentine to a greater extent than that of rifampicin. Until more pharmacokinetic information and information on the safety of rifapentine use in diabetic patients and drug–drug interactions are available, diabetes in TB patients treated with rifapentine should be managed with insulin analogs, and glucose and rifapentine plasma levels should be closely monitored.
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Affiliation(s)
- Chunlan Zheng
- Department of Internal Medicine - Section 5, Wuhan Pulmonary Hospital (Wuhan Tuberculosis Control Institute)
| | - Xiufen Hu
- Department of Paediatrics, Tongji Hospital
| | - Li Zhao
- Department of Internal Medicine - Section 5, Wuhan Pulmonary Hospital (Wuhan Tuberculosis Control Institute)
| | - Minhui Hu
- Department of Internal Medicine - Section 5, Wuhan Pulmonary Hospital (Wuhan Tuberculosis Control Institute)
| | - Feng Gao
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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RSSDI clinical practice recommendations for diagnosis, prevention, and control of the diabetes mellitus-tuberculosis double burden. Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-017-0577-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Abstract
The increase in type 2 diabetes mellitus (DM) patients in countries where tuberculosis (TB) is also endemic has led to the reemerging importance of DM as a risk factor for TB. DM causes a 3-fold increase in TB risk and a 2-fold increase in adverse TB treatment outcomes. Given the sheer numbers of DM patients worldwide, there are now more TB patients with TB-DM comorbidity than TB-HIV coinfection. There is an urgent need to implement strategies for TB prevention and control among the millions of DM patients exposed to Mycobacterium tuberculosis. This chapter summarizes the current epidemiological, clinical, and immunological knowledge on TB and DM and their clinical and public health implications. These include the underlying mechanisms for TB risk in DM patients and their clinical and sociodemographic characteristics that distinguish them from TB patients without DM. TB-DM comorbidity is posing a new challenge for integrating the short-term care for TB with the long-term care for DM, particularly in low- and middle-income countries.
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Ramachandran G, Agibothu Kupparam HK, Vedhachalam C, Thiruvengadam K, Rajagandhi V, Dusthackeer A, Karunaianantham R, Jayapal L, Swaminathan S. Factors Influencing Tuberculosis Treatment Outcome in Adult Patients Treated with Thrice-Weekly Regimens in India. Antimicrob Agents Chemother 2017; 61:e02464-16. [PMID: 28242663 PMCID: PMC5404592 DOI: 10.1128/aac.02464-16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/09/2017] [Indexed: 11/20/2022] Open
Abstract
The Indian Revised National Tuberculosis (TB) Control Programme uses thrice-weekly treatment with standard drug dosages. The role of plasma drug levels and other factors in determining TB treatment outcomes is not well understood. We aimed to determine the factors influencing the concentrations of rifampin (RMP), isoniazid (INH), and pyrazinamide (PZA) at 2 h postdosing in adult TB patients and to study the factors impacting TB treatment outcome. We recruited 1,912 adult TB patients (newly treated and retreated patients) with pulmonary/extrapulmonary TB receiving antitubercular treatment (ATT) in the RNTCP in Chennai, India. At steady state, the concentrations of RMP, INH, and PZA were determined at 2 h postdosing after supervised drug administration. A total of 1,648 patients had a favorable outcome, while 264 (14%) had an unfavorable outcome. A total of 91%, 16%, and 17% of the patients had suboptimal concentrations of RMP (<8 μg/ml), INH (<3 μg/ml), and PZA (<20 μg/ml), respectively. Factors associated with treatment outcome were low RMP concentrations (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.89 to 0.99; P = 0.036), category II ATT (aOR, 2.39; 95% CI, 1.56 to 3.65; P < 0.001), low body weight (aOR, 0.96; 95% CI, 0.94 to 0.98; P < 0.001), alcohol use (aOR, 2.17; 95% CI, 1.42 to 3.31; P < 0.001), male gender (aOR, 1.92; 95% CI, 1.02 to 3.62; P = 0.043), and baseline INH resistance (aOR, 5.74; 95% CI, 3.12 to 10.59; P < 0.001), which significantly increased the likelihood of an unfavorable outcome in multivariate logistic regression analysis. Further studies are needed to optimize anti-TB drug dosages and improve cure rates. Drug susceptibility testing at the baseline and attention to undernutrition and alcohol dependence are other important interventions.
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Aftab H, Ambreen A, Jamil M, Garred P, Petersen JH, Nielsen SD, Bygbjerg IC, Christensen DL. High prevalence of diabetes and anthropometric heterogeneity among tuberculosis patients in Pakistan. Trop Med Int Health 2017; 22:465-473. [PMID: 28102021 DOI: 10.1111/tmi.12842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In Pakistan, the prevalence of diabetes (DM) among adults is 6.9% and expected to double by 2040. DM may facilitate transmission and halter the elimination of tuberculosis (TB). We aimed to determine the prevalence of DM among patients with TB in Pakistan, and to investigate anthropometric biochemical and haemodynamic associations between TB patients with and without DM. METHODS We conducted a cross-sectional study at Gulab Devi Chest Hospital in Lahore, Punjab. A total of 3027 newly diagnosed smear-positive TB patients ≥25 years of age were screened for DM by HbA1c regardless of previous DM history. RESULTS The prevalence of screen-detected DM and known DM among the TB participants was 13.5% and 26.1%, respectively, resulting in a combined DM prevalence of 39.6%. Most participants were male (64.4%). Using bivariate analyses, participants with DM were significantly older (49.8 vs. 40.6 years) with higher haemoglobin (men, 12.1 vs. 11.8 g/dl, women 11.5 vs. 10.7 g/dl), body mass index (21.0 vs. 17.6 kg/m2 ) and waist-hip ratio (men, 0.87 vs. 0.81, women, 0.87 vs. 0.79) (all P < 0.05) than participants without DM. Stratifying by screen-detected and known DM, these differences remained significant when using multivariate analysis. CONCLUSION We report a high prevalence of DM among patients with TB who may be anthropometrically and biochemically distinct from TB patients without DM, and this heterogeneity further transcends the different DM groups.
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Affiliation(s)
- Huma Aftab
- Section of Global Health, Department of Public Health, University of Copenhagen, Denmark
| | | | | | - Peter Garred
- Laboratory of Molecular Medicine, Rigshospitalet, Denmark
| | - Jørgen H Petersen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Denmark
| | - Susanne D Nielsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ib C Bygbjerg
- Section of Global Health, Department of Public Health, University of Copenhagen, Denmark
| | - Dirk L Christensen
- Section of Global Health, Department of Public Health, University of Copenhagen, Denmark
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Perez-Navarro LM, Restrepo BI, Fuentes-Dominguez FJ, Duggirala R, Morales-Romero J, López-Alvarenga JC, Comas I, Zenteno-Cuevas R. The effect size of type 2 diabetes mellitus on tuberculosis drug resistance and adverse treatment outcomes. Tuberculosis (Edinb) 2017; 103:83-91. [PMID: 28237037 DOI: 10.1016/j.tube.2017.01.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/19/2017] [Accepted: 01/21/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the effect size of type 2 diabetes mellitus (T2DM) on tuberculosis (TB) treatment outcomes and multi drug resistance (MDR). METHODS A cohort with 507 individuals with diagnosed TB included 183 with coexistence of T2DM and TB (TB-T2DM). Participants were identified at the time of TB diagnosis and followed during the course of TB treatment. Then we computed relative risks and adjustments by Cox proportional hazards for outcome variables (drug resistance, death, relapse, treatment failure), and the size of their effect as Cohen's-d. RESULTS Patients with TB-T2DM were more likely to remain positive for acid-fast bacilli after two months of anti-TB treatment RR = [2.01 (95% CI: 1.3, 3.1)], to have drug resistant (DR) [OR 3.5 (95% CI: 1.8, 6.7)] and multi-drug resistant (MDR) TB [OR 3.5 (95% CI: 1.8, 7.1)]. The Cohen's-d for DR or MDR in T2DM was 0.69 when compared with non-DM subjects. The T2DM patients had higher odds of resistance to isoniazid (OR 3.9, 95% CI: 2.01, 7.9), rifampicin (OR 3.4, 95% CI: 1.6, 7.2) and pyrazinamide (OR 9.4, 95% CI: 2.8, 25.6), and their effect sizes were ≥0.67. Patients with TB-T2DM (versus no DM) were more likely to present with MDR TB (HR 3.1; 95% CI: 1.7, 5.8; p < 0.001), treatment failure (HR 2.04; 95% CI: 1.07, 3.8; p = 0.02) and relapse (HR 1.86; 95% CI: 1.09, 3.1; p = 0.02), with effect size ≥0.34. CONCLUSION T2DM showed a substantial contribution to the presence of DR or MDR-TB and to adverse clinical outcomes during and after TB treatment. Our findings support the importance for routine screening of T2DM among newly-diagnosed TB patients in order to stratify them for immediate DR assessment, and highlight the need for clinical trials to evaluate variations to the standard TB treatment in TB-T2DM to prevent adverse treatment outcomes.
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Affiliation(s)
- Lucia Monserrat Perez-Navarro
- Nephrology Service, Research Division, Hospital General de México "Dr. Eduardo Liceaga", Mexico; Public Health Institute, University of Veracruz, Veracruz, Mexico
| | - Blanca I Restrepo
- University of Texas Health Science Center Houston, Brownsville Campus, Brownsville, TX, USA
| | | | - Ravindranath Duggirala
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Edinburg, TX, USA
| | | | | | - Iñaki Comas
- Unidad de Genómica de la Tuberculosis, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | - Roberto Zenteno-Cuevas
- Public Health Institute, University of Veracruz, Veracruz, Mexico; Red multidisciplinaria de Investigación en tuberculosis, Mexico.
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Muñoz-Torrico M, Caminero-Luna J, Migliori GB, D'Ambrosio L, Carrillo-Alduenda JL, Villareal-Velarde H, Torres-Cruz A, Flores-Vergara H, Martínez-Mendoza D, García-Sancho C, Centis R, Salazar-Lezama MÁ, Pérez-Padilla R. Diabetes is Associated with Severe Adverse Events in Multidrug-Resistant Tuberculosis. Arch Bronconeumol 2017; 53:245-250. [PMID: 28089216 DOI: 10.1016/j.arbres.2016.10.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Diabetes mellitus (DM), a very common disease in Mexico, is a well-known risk factor for tuberculosis (TB). However, it is not known by which extent DM predisposes to adverse events (AE) to anti-TB drugs and/or to worse outcomes in patients with multidrug-resistant (MDR-TB) and extensively drug-resistant TB (XDR-TB). The main objective of this study was to describe the outcomes of TB treatment, the impact of DM and the prevalence of AE in a cohort of patients with MDR-/XDR pulmonary TB treated at the national TB referral centre in Mexico City. RESULTS Ninety patients were enrolled between 2010 and 2015: 73 with MDR-TB (81.1%), 11 with pre-XDR-TB (12.2%) and 6 (6.7%) with XDR-TB, including 49 (54.4%) with DM, and 3 with Human Immunodeficiency Virus (HIV) co-infection (3.3%). In 98% of patients, diagnosis was made by culture and drug susceptibility testing, while in a single case the diagnosis was made by a molecular test. The presence of DM was associated with an increased risk of serious drug-related AEs, such as nephrotoxicity (Odds Ratio [OR]=6.5; 95% Confidence Interval [95% CI]: 1.9-21.8) and hypothyroidism (OR=8.8; 95% CI: 1.8-54.2), but not for a worse outcome. CONCLUSIONS Our data suggest that DM does not impact second-line TB treatment outcomes, but patients with DM have a higher risk of developing serious AEs to drug-resistant TB treatment, such as nephrotoxicity and hypothyroidism.
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Affiliation(s)
- Marcela Muñoz-Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - José Caminero-Luna
- Departamento de Neumología, Hospital Universitario de Gran Canaria «Dr. Negrín», Las Palmas, Canarias, España
| | | | - Lia D'Ambrosio
- WHO Collaborating Centre for TB and Lung Diseases, Maugeri Institute, IRCCS, Tradate, Italia; Public Health Consulting Group, Lugano, Suiza
| | - José Luis Carrillo-Alduenda
- Clínica del Sueño, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Héctor Villareal-Velarde
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Alfredo Torres-Cruz
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Héctor Flores-Vergara
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Dina Martínez-Mendoza
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Cecilia García-Sancho
- Departamento de Epidemiología, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Rosella Centis
- WHO Collaborating Centre for TB and Lung Diseases, Maugeri Institute, IRCCS, Tradate, Italia
| | - Miguel Ángel Salazar-Lezama
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
| | - Rogelio Pérez-Padilla
- Clínica del Sueño, Instituto Nacional de Enfermedades Respiratorias de México (INER), Ciudad de México, México
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Devaleenal Daniel B, Ramachandran G, Swaminathan S. The challenges of pharmacokinetic variability of first-line anti-TB drugs. Expert Rev Clin Pharmacol 2016; 10:47-58. [PMID: 27724114 DOI: 10.1080/17512433.2017.1246179] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Inter-individual variations in the pharmacokinetics (PK) of anti-TB drugs are known to occur, which could have important therapeutic implications in patient management. Areas covered: We compiled factors responsible for PK variability of anti-TB drugs reported from different settings that would give a better understanding about the challenges of PK variability of anti-TB medications. We searched PubMed data base and Google scholar from 1976 to the present using the key words 'Pharmacokinetics', 'pharmacokinetic variability', 'first-line anti-TB therapy', 'Rifampicin', 'Isoniazid', 'Ethambutol', 'Pyrazinamide', 'food', 'nutritional status', 'HIV', 'diabetes', 'genetic polymorphisms' and 'pharmacokinetic interactions'. We also included abstracts from scientific meetings and review articles. Expert commentary: A variety of host and genetic factors can cause inter-individual variations in the PK of anti-TB drugs. PK studies conducted in various settings have adopted different designs, PK sampling time points, drug estimation methodologies. Hence comparison and interpretation of these results should be done with caution More phamacogenomic studies in different patient populations are needed for further understanding.
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Affiliation(s)
- Bella Devaleenal Daniel
- a Department of Clinical Research , National Institute for Research in Tuberculosis , Chennai , Tamil Nadu , India
| | - Geetha Ramachandran
- a Department of Clinical Research , National Institute for Research in Tuberculosis , Chennai , Tamil Nadu , India
| | - Soumya Swaminathan
- b Secretary Department of Health Research & Director General , Indian Council of Medical Research , New Delhi , India
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HIV-1 Coinfection Does Not Reduce Exposure to Rifampin, Isoniazid, and Pyrazinamide in South African Tuberculosis Outpatients. Antimicrob Agents Chemother 2016; 60:6050-9. [PMID: 27480859 PMCID: PMC5038257 DOI: 10.1128/aac.00480-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/20/2016] [Indexed: 02/07/2023] Open
Abstract
There are contrasting data in the literature about antituberculosis plasma drug concentrations in HIV-1-coinfected patients. We report the pharmacokinetics of rifampin, isoniazid, and pyrazinamide in a cohort of patients being treated for active tuberculosis, the majority of whom were coinfected with HIV-1 and had commenced antiretroviral therapy within 2 months of starting antituberculosis treatment. We also examined the association between antituberculosis drug concentrations and reported drug side effects at the 2-month clinical review. One hundred patients with pulmonary tuberculosis (65% coinfected with HIV-1) were intensively sampled to determine rifampin, isoniazid, and pyrazinamide plasma concentrations after 7 to 8 weeks of a daily quadruple-therapy regimen dosed according to World Health Organization (WHO) weight bands. Pharmacokinetic parameters were determined for each patient by using nonlinear mixed-effects models. HIV-1-coinfected patients had lower clearance rates for rifampin (21% decrease) and isoniazid (23% decrease) than HIV-1-uninfected patients, with resulting higher areas under the concentration-time curve from 0 to 24 h (AUC0–24) and maximum concentrations of drug in serum (Cmax). Antiretroviral therapy (ART) that included double-standard-dose lopinavir/ritonavir further lowered rifampin clearance, by 46%, and increased the AUC0–24. The current uniform dosing (per kilogram of body weight) across WHO weight bands was associated with a trend of decreased pharmacokinetic exposures for the lowest weight band. Use of fat-free mass as opposed to total body weight for allometric scaling of clearance significantly improved the model. Ambulant HIV-1-coinfected patients, the majority of whom were coprescribed ART, did not have reduced antituberculosis drug concentrations compared to HIV-1-uninfected patients.
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Anti-tuberculosis drug concentrations in tuberculosis patients with and without diabetes mellitus. Eur J Clin Pharmacol 2016; 73:65-70. [PMID: 27651240 DOI: 10.1007/s00228-016-2132-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/09/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of the study was to compare plasma concentrations of rifampicin (RMP), isoniazid (INH) and pyrazinamide (PZA) between tuberculosis (TB) patients with and without diabetes mellitus (DM). METHODS Two-hour post-dosing concentrations of RMP, INH and PZA were determined in adult TB patients that were studied with (n = 452) and without DM (n = 1460), treated with a thrice-weekly regimen in India. Drug concentrations were estimated by HPLC. RESULTS The median (IQR) INH [6.6 (3.9-10.0) and 7.8 (4.6-11.3)] and PZA [31.0 (22.3-38.0) and 34.1 (24.6-42.7)] microgram per milliliter concentrations were significantly lower in diabetic than non-diabetic TB patients (p < 0.001 for both drugs). Blood glucose was negatively correlated with plasma INH (r = -0.09, p < 0.001) and PZA (r = -0.092, p < 0.001). Multiple linear regression analysis showed RMP, INH and PZA concentrations were influenced by age and drug doses, INH and PZA by DM, RMP by alcohol use and PZA by gender and category of ATT. DM reduced INH and PZA concentrations by 0.8 and 3.0 μg/ml, respectively. CONCLUSIONS TB patients with DM had lower INH and PZA concentrations. Negative correlation between blood glucose and drug concentrations suggests delayed absorption/faster elimination of INH and PZA in the presence of elevated glucose.
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Yoon YS, Jung JW, Jeon EJ, Seo H, Ryu YJ, Yim JJ, Kim YH, Lee BH, Park YB, Lee BJ, Kang H, Choi JC. The effect of diabetes control status on treatment response in pulmonary tuberculosis: a prospective study. Thorax 2016; 72:263-270. [PMID: 27553224 DOI: 10.1136/thoraxjnl-2015-207686] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 05/25/2016] [Accepted: 07/12/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Uncontrolled diabetes, unlike controlled diabetes, is associated with an impaired immune response. However, little is known about the impact of the status of diabetes control on clinical features and treatment outcomes in patients with pulmonary TB (PTB). We conducted this study to evaluate whether the status of diabetes control influences clinical manifestations and treatment responses in PTB. METHODS A multicentre prospective study was performed between September 2012 and September 2014. The patients were categorised into three groups according to the glycated haemoglobin (HbA1C) level: PTB without diabetes mellitus (non-DM), PTB with controlled diabetes (controlled-DM) and PTB with uncontrolled diabetes (uncontrolled-DM). The primary outcome was the sputum culture conversion rate after 2 months of intensive treatment. RESULTS Among 661 patients with PTB, 157 (23.8%) had diabetes and 108 (68.8%) had uncontrolled diabetes (HbA1C≥7.0%). The uncontrolled-DM group exhibited more symptoms, positive sputum smears (p<0.001) and presence of cavities (p<0.001) than the non-DM group. Regarding treatment responses, patients with uncontrolled-DM were more likely to have a positive culture after 2 months (p=0.009) and either treatment failure (p=0.015) or death (p=0.027) compared with the non-DM group. In contrast, those with controlled-DM showed similar treatment responses to the non-DM group. In multivariable analysis, uncontrolled diabetes was an independent risk factor for a positive sputum culture after 2 months of treatment (adjusted OR, 2.11; p=0.042) and either treatment failure or death (adjusted OR, 4.11; p=0.022). CONCLUSIONS Uncontrolled diabetes is an independent risk factor for poor treatment response in PTB.
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Affiliation(s)
- Young Soon Yoon
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, South Korea
| | - Jae-Woo Jung
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung-Ang University, School of Medicine, Seoul, South Korea
| | - Eun Ju Jeon
- Department of Internal Medicine, Hallym Hospital, Incheon, South Korea
| | - Haesook Seo
- Department of Tuberculosis, Seobuk Hospital, Seoul Metropolitan Government, Seoul, South Korea
| | - Yon Ju Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Womans University, School 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
| | - Yee Hyung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Byoung-Hoon Lee
- Department of Pulmonology and Allergy, Eulji Hospital, College of Medicine, Eulji University, Seoul, South Korea
| | - Yong Bum Park
- Department of Internal Medicine, Hallym University Medical Center, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Byoung Jun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, South Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University, School of Medicine, Seoul, South Korea
| | - Jae Chol Choi
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung-Ang University, School of Medicine, Seoul, South Korea
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Verbeeck RK, Günther G, Kibuule D, Hunter C, Rennie TW. Optimizing treatment outcome of first-line anti-tuberculosis drugs: the role of therapeutic drug monitoring. Eur J Clin Pharmacol 2016; 72:905-16. [PMID: 27305904 DOI: 10.1007/s00228-016-2083-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Tuberculosis (TB) remains one of the world's deadliest communicable diseases. Although cure rates of the standard four-drug (rifampicin, isoniazid, pyrazinamide, ethambutol) treatment schedule can be as high as 95-98 % under clinical trial conditions, success rates may be much lower in less well resourced countries. Unsuccessful treatment with these first-line anti-TB drugs may lead to the development of multidrug resistant and extensively drug resistant TB. The intrinsic interindividual variability in the pharmacokinetics (PK) of the first-line anti-TB drugs is further exacerbated by co-morbidities such as HIV infection and diabetes. METHODS Therapeutic drug monitoring has been proposed in an attempt to optimize treatment outcome and reduce the development of drug resistance. Several studies have shown that maximum plasma concentrations (C max), especially of rifampicin and isoniazid, are well below the proposed target C max concentrations in a substantial fraction of patients being treated with the standard four-drug treatment schedule, even though treatment's success rate in these studies was typically at least 85 %. DISCUSSION The proposed target C max concentrations are based on the concentrations of these agents achieved in healthy volunteers and patients receiving the standard doses. Estimation of C max based on one or two sampling times may not have the necessary accuracy since absorption rate, especially for rifampicin, may be highly variable. In addition, minimum inhibitory concentration (MIC) variability should be taken into account to set clinically meaningful susceptibility breakpoints. Clearly, there is a need to better define the key target PK and pharmacodynamic (PD) parameters for therapeutic drug monitoring (TDM) of the first-line anti-TB drugs to be efficacious, C max (or area under the curve (AUC)) and C max/MIC (or AUC/MIC). CONCLUSION Although TDM of first-line anti-TB drugs has been successfully used in a limited number of specialized centers to improve treatment outcome in slow responders, a better characterization of the target PK and/or PK/PD parameters is in our opinion necessary to make it cost-effective.
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Affiliation(s)
- Roger K Verbeeck
- Faculty of Health Sciences, University of Namibia, Windhoek, Namibia.
| | - Gunar Günther
- Katutura State Hospital, Windhoek, Namibia.,Leibniz Center for Medicine and Biosciences, Borstel, Germany
| | - Dan Kibuule
- Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Christian Hunter
- Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Tim W Rennie
- Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
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49
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Rifampin resistance and diabetes mellitus in a cross-sectional study of adult patients in rural South India. BMC Infect Dis 2015; 15:451. [PMID: 26496855 PMCID: PMC4620627 DOI: 10.1186/s12879-015-1204-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 10/12/2015] [Indexed: 11/10/2022] Open
Abstract
Background Despite increasing reports of the linkage between diabetes and tuberculosis (TB), there is limited information regarding diabetes and TB drug resistance. Methods In this cross-sectional study, sputum and blood samples were collected from 304 adult patients in rural Andhra Pradesh. Rifampin resistance was assessed by Xpert MTB/RIF (Xpert), and diabetes status was based on self-report. Additionally, samples were assayed by acid-fast bacilli sputum smear microscopy (AFB) and QuantiFERON-TB Gold In-Tube (QFT-G), in order to compare relative diagnostic performances. Results Among patients with confirmed TB (n = 194), diabetes was associated with 3.0-fold higher risk of rifampin resistance (95 % CI 1.3–6.7). Considering Xpert MTB/RIF the gold standard, AFB had lower sensitivity (72.2 vs. 82.5 %) and higher specificity (96.4 vs. 37.0 %) compared to QFT-G for diagnosing TB. Conclusions The increased risk of rifampin resistance in patients with diabetes highlights the need for integrated diabetes surveillance in TB programs, particularly in settings undergoing the epidemiological transition. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1204-5) contains supplementary material, which is available to authorized users.
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50
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Alkabab YM, Al-Abdely HM, Heysell SK. Diabetes-related tuberculosis in the Middle East: an urgent need for regional research. Int J Infect Dis 2015; 40:64-70. [PMID: 26409203 PMCID: PMC4863943 DOI: 10.1016/j.ijid.2015.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 08/21/2015] [Accepted: 09/16/2015] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Diabetes mellitus (DM) triples the risk of tuberculosis (TB) disease, complicates TB treatment, and increases the risk of a poor TB outcome. As DM prevalence is increasing across the Middle East, this review was performed to identify regional gaps in knowledge and research priorities for DM/TB. METHODS Online databases were searched for studies published from Middle East countries on DM and TB and the studies summarized based on topic and major findings. Studies included had a principle hypothesis related to both diseases, or described TB patients with individual data on DM. RESULTS Fifty-nine studies from 10 countries met search criteria. No published studies were found from Lebanon, Bahrain, Syria, Jordan, Cyprus, or the United Arab Emirates. DM prevalence among TB patients was high, but varied considerably across studies. The vast majority of studies were not specifically designed to compare DM/TB and non-DM/TB patients, but many suggested worse treatment outcomes for DM/TB, in accordance with reports from other regions. CONCLUSIONS Opportunity exists for the regional study of bidirectional screening, management strategies for both DM and TB diseases, and whether such efforts could take place through the integration of services.
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Affiliation(s)
- Yosra M Alkabab
- Division of Infectious Diseases, King Khalid University Hospital, Riyadh, Saudi Arabia.
| | - Hail M Al-Abdely
- Division of Infectious Diseases, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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