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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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Abouzid M, Kosicka-Noworzyń K, Karaźniewicz-Łada M, Rao P, Modi N, Xie YL, Heysell SK, Główka A, Kagan L. Development and Validation of a UPLC-MS/MS Method for Therapeutic Drug Monitoring, Pharmacokinetic and Stability Studies of First-Line Antituberculosis Drugs in Urine. Molecules 2024; 29:337. [PMID: 38257250 PMCID: PMC10818978 DOI: 10.3390/molecules29020337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Tuberculosis (TB) remains one of the leading global causes of mortality. Several methods have been established to detect anti-TB agents in human plasma and serum. However, there is a notable absence of studies analyzing TB drugs in urine. Thus, our objective was to validate a method for quantifying first-line anti-TB agents: isoniazid (INH), pyrazinamide (PZA), ethambutol (ETH), and rifampicin (RIF), along with its metabolite 25-desacetylrifampicin, and degradation products: rifampicin quinone and 3-formyl-rifampicin in 10 µL of urine. Chromatographic separation was achieved using a Kinetex Polar C18 analytical column with gradient elution (5 mM ammonium acetate and acetonitrile with 0.1% formic acid). Mass spectrometry detection was carried out using a triple-quadrupole tandem mass spectrometer operating in positive ion mode. The lower limit of quantification (LLOQ) was 0.5 µg/mL for INH, PZA, ETH, and RIF, and 0.1 µg/mL for RIF's metabolites and degradation products. The method was validated following FDA guidance criteria and successfully applied to the analysis of the studied compounds in urine of TB patients. Additionally, we conducted a stability study of the anti-TB agents under various pH and temperature conditions to mimic the urine collection process in different settings (peripheral clinics or central laboratories).
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Affiliation(s)
- Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 3 Rokietnicka Street, 60-806 Poznań, Poland; (M.A.); (K.K.-N.)
- Doctoral School, Poznan University of Medical Sciences, 70 Bukowska Street, 60-812 Poznań, Poland
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Katarzyna Kosicka-Noworzyń
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 3 Rokietnicka Street, 60-806 Poznań, Poland; (M.A.); (K.K.-N.)
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 3 Rokietnicka Street, 60-806 Poznań, Poland; (M.A.); (K.K.-N.)
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Prakruti Rao
- Division of Infectious Diseases and International Health, University of Virginia, 345 Crispell Drive, Charlottesville, VA 22903, USA; (P.R.); (S.K.H.)
| | - Nisha Modi
- Public Health Research Institute, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07013, USA; (N.M.); (Y.L.X.)
| | - Yingda L. Xie
- Public Health Research Institute, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07013, USA; (N.M.); (Y.L.X.)
| | - Scott K. Heysell
- Division of Infectious Diseases and International Health, University of Virginia, 345 Crispell Drive, Charlottesville, VA 22903, USA; (P.R.); (S.K.H.)
| | - Anna Główka
- Department of Bromatology, Poznan University of Medical Sciences, 3 Rokietnicka Street, 60-806 Poznań, Poland;
| | - Leonid Kagan
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
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Therapeutic Drug Monitoring of Ivacaftor, Lumacaftor, Tezacaftor, and Elexacaftor in Cystic Fibrosis: Where Are We Now? Pharmaceutics 2022; 14:pharmaceutics14081674. [PMID: 36015300 PMCID: PMC9412421 DOI: 10.3390/pharmaceutics14081674] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 11/16/2022] Open
Abstract
Drugs modulating the cystic fibrosis transmembrane conductance regulator (CFTR) protein, namely ivacaftor, lumacaftor, tezacaftor, and elexacaftor, are currently revolutionizing the management of patients with cystic fibrosis (CF), particularly those with at least one F508del variant (up to 85% of patients). These “caftor” drugs are mainly metabolized by cytochromes P450 3A, whose enzymatic activity is influenced by environmental factors, and are sensitive to inhibition and induction. Hence, CFTR modulators are characterized by an important interindividual pharmacokinetic variability and are also prone to drug–drug interactions. However, these CFTR modulators are given at standardized dosages, while they meet all criteria for a formal therapeutic drug monitoring (TDM) program that should be considered in cases of clinical toxicity, less-than-expected clinical response, drug or food interactions, distinct patient subgroups (i.e., pediatrics), and for monitoring short-term adherence. While the information on CFTR drug exposure–clinical response relationships is still limited, we review the current evidence of the potential interest in the TDM of caftor drugs in real-life settings.
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Anderson G, Vinnard C. Diagnostic Accuracy of Therapeutic Drug Monitoring During Tuberculosis Treatment. J Clin Pharmacol 2022; 62:1206-1214. [PMID: 35588142 PMCID: PMC9541759 DOI: 10.1002/jcph.2068] [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: 01/07/2022] [Accepted: 04/29/2022] [Indexed: 11/06/2022]
Abstract
Tuberculosis (TB) patients co-infected with human immunodeficiency virus (HIV) are more likely to have low blood concentrations of the first-line anti-TB drugs (associated with poor outcomes). Therapeutic drug monitoring (TDM) is recommended for certain TB patient populations at increased risk for a poor outcome. Our objective was to estimate the diagnostic accuracy of a 2-hour TDM serum sample for the first-line anti-TB drugs among HIV/TB patients, and evaluate the information gained by an additional 6-hour sample. We created a virtual (n = 1,000) HIV/TB patient population and performed pharmacokinetic (PK) simulations using published population models for isoniazid, rifampin, pyrazinamide, and ethambutol. We performed receiver-operating-characteristic (ROC) analysis to compare the diagnostic performance of a single 2-hour serum sample with samples obtained at 2- and 6-hours post-dosing. The sensitivity of a single 2-hour serum concentration to identify HIV/TB patients with adequate serum exposures was lowest for rifampin (54.9%, 95% CI 50.79-59.41%) and highest for ethambutol (70.8%, 95% CI 66.06-72.61%) for Cmax targets. Diagnostic accuracy of a single 2-hour serum sample for the AUC0-24 target was highest for isoniazid (93%, 95% CI 90.9-94.1%) and lowest for pyrazinamide (66.3%, 95% CI 62.6-70.0%). In summary, the diagnostic performance of TDM for Cmax and AUC0-24 targets demonstrated variability across the first-line anti-TB drugs. The addition of a 6-hour serum sample lead to the highest statistically significant improvement (p < 0.001) and highest increase in diagnostic accuracy (area under the ROC curve) for rifampin for Cmax and AUC. The other first-line drugs had modest/negligible increases in diagnostic accuracy. This article is protected by copyright. All rights reserved.
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Shi J, He G, Ning H, Wu L, Wu Z, Ye X, Qiu C, Jiang X. Application of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) in the detection of drug resistance of Mycobacterium tuberculosis in re-treated patients. Tuberculosis (Edinb) 2022; 135:102209. [DOI: 10.1016/j.tube.2022.102209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/24/2022] [Indexed: 12/28/2022]
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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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Tornheim JA, Udwadia ZF, Arora PR, Gajjar I, Sharma S, Karane M, Sawant N, Kharat N, Blum AJ, Shivakumar SVBY, Gupte AN, Gupte N, Mullerpattan JB, Pinto LM, Ashavaid TF, Gupta A, Rodrigues C. Increased Moxifloxacin Dosing Among Patients With Multidrug-Resistant Tuberculosis With Low-Level Resistance to Moxifloxacin Did Not Improve Treatment Outcomes in a Tertiary Care Center in Mumbai, India. Open Forum Infect Dis 2021; 9:ofab615. [PMID: 35097152 PMCID: PMC8794589 DOI: 10.1093/ofid/ofab615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/01/2021] [Indexed: 12/02/2022] Open
Abstract
Background Mycobacterium tuberculosis (Mtb) strains resistant to isoniazid and rifampin (multidrug-resistant tuberculosis [MDR-TB]) are increasingly reported worldwide, requiring renewed focus on the nuances of drug resistance. Patients with low-level moxifloxacin resistance may benefit from higher doses, but limited clinical data on this strategy are available. Methods We conducted a 5-year observational cohort study of MDR-TB patients at a tertiary care center in India. Participants with Mtb isolates resistant to isoniazid, rifampin, and moxifloxacin (at the 0.5 µg/mL threshold) were analyzed according to receipt of high-dose moxifloxacin (600 mg daily) as part of a susceptibility-guided treatment regimen. Univariable and multivariable Cox proportional hazard models assessed the relationship between high-dose moxifloxacin and unfavorable treatment outcomes. Results Of 354 participants with MDR-TB resistant to moxifloxacin, 291 (82.2%) received high-dose moxifloxacin. The majority experienced good treatment outcomes (200 [56.5%]), which was similar between groups (56.7% vs 54.0%, P = .74). Unfavorable outcomes were associated with greater extent of radiographic disease, lower initial body mass index, and concurrent treatment with fewer drugs with confirmed phenotypic susceptibility. Treatment with high-dose moxifloxacin was not associated with improved outcomes in either unadjusted (hazard ratio [HR], 1.2 [95% confidence interval {CI}, .6–2.4]) or adjusted (HR, 0.8 [95% CI, .5–1.4]) models but was associated with joint pain (HR, 3.2 [95% CI, 1.2–8.8]). Conclusions In a large observational cohort, adding high-dose (600 mg) moxifloxacin to a drug susceptibility test–based treatment regimen for MDR-TB was associated with increased treatment-associated side effects without improving overall outcomes and should be avoided for empiric treatment of moxifloxacin-resistant MDR-TB.
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Affiliation(s)
- Jeffrey A Tornheim
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zarir F Udwadia
- Department of Respiratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Prerna R Arora
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ishita Gajjar
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Samridhi Sharma
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Megha Karane
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Namrata Sawant
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Nisha Kharat
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Alexander J Blum
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Akshay N Gupte
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nikhil Gupte
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins University–India Office (Center for Clinical Global Health Education), Pune, Maharashtra, India
| | - Jai B Mullerpattan
- Department of Respiratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Lancelot M Pinto
- Department of Respiratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Tester F Ashavaid
- Department of Laboratory Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Amita Gupta
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Camilla Rodrigues
- Department of Microbiology, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Abstract
Mycobacterium tuberculosis is a major public health concern and requires prompt treatment. Goals of treatment include curing the individual patient and protecting the community from ongoing tuberculosis transmission. To achieve durable cure, regimens must include multiple agents given concurrently and in a manner to ensure completion of therapy. This article focuses on preferred regimens of drug-susceptible tuberculosis under current guidelines by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America and World Health Organization. In addition, topics including patient centered care, poor treatment outcomes, and adverse effects are also discussed.
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Affiliation(s)
- Beth Shoshana Zha
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0111, 513 Parnassus Avenue, San Francisco, CA 94117, USA
| | - Payam Nahid
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0841 MD, 1001 Potrero Avenue, 5J6, San Francisco, CA 94110, USA.
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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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