1
|
Ryckman TS, Schumacher SG, Lienhardt C, Sweeney S, Dowdy DW, Mirzayev F, Kendall EA. Economic implications of novel regimens for tuberculosis treatment in three high-burden countries: a modelling analysis. Lancet Glob Health 2024; 12:e995-e1004. [PMID: 38762299 PMCID: PMC11126367 DOI: 10.1016/s2214-109x(24)00088-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/24/2024] [Accepted: 02/21/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND With numerous trials investigating novel drug combinations to treat tuberculosis, we aimed to evaluate the extent to which future improvements in tuberculosis treatment regimens could offset potential increases in drug costs. METHODS In this modelling analysis, we used an ingredients-based approach to estimate prices at which novel regimens for rifampin-susceptible and rifampin-resistant tuberculosis treatment would be cost-neutral or cost-effective compared with standards of care in India, the Philippines, and South Africa. We modelled regimens meeting targets set in the WHO's 2023 Target Regimen Profiles (TRPs). Our decision-analytical model tracked cohorts of adults initiating rifampin-susceptible or rifampin-resistant tuberculosis treatment, simulating their health outcomes and costs accumulated during and following treatment under standard-of-care and novel regimen scenarios. Price thresholds included short-term cost-neutrality (considering only savings accrued during treatment), medium-term cost-neutrality (additionally considering savings from averted retreatments and secondary cases), and cost-effectiveness (incorporating willingness-to-pay for improved health outcomes). FINDINGS Total medium-term costs per person treated using standard-of-care regimens were estimated at US$450 (95% uncertainty interval 310-630) in India, $560 (350-860) in the Philippines, and $730 (530-1090) in South Africa for rifampin-susceptible tuberculosis (current drug costs $46) and $2100 (1590-2810) in India, $2610 (2090-3280) in the Philippines, and $3790 (3090-4630) in South Africa for rifampin-resistant tuberculosis (current drug costs $432). A rifampin-susceptible tuberculosis regimen meeting the optimal targets defined in the TRPs could be cost-neutral in the short term at drug costs of $140 (90-210) per full course in India, $230 (130-380) in the Philippines, and $280 (180-460) in South Africa. For rifampin-resistant tuberculosis, short-term cost-neutral thresholds were higher with $930 (720-1230) in India, $1180 (980-1430) in the Philippines, and $1480 (1230-1780) in South Africa. Medium-term cost-neutral prices were approximately $50-100 higher than short-term cost-neutral prices for rifampin-susceptible tuberculosis and $250-550 higher for rifampin-resistant tuberculosis. Health system cost-neutral prices that excluded patient-borne costs were 45-70% lower (rifampin-susceptible regimens) and 15-50% lower (rifampin-resistant regimens) than the cost-neutral prices that included patient costs. Cost-effective prices were substantially higher. Shorter duration was the most important driver of medium-term savings with novel regimens, followed by ease of adherence. INTERPRETATION Improved tuberculosis regimens, particularly shorter regimens or those that facilitate better adherence, could reduce overall costs, potentially offsetting higher prices. FUNDING WHO.
Collapse
Affiliation(s)
- Theresa S Ryckman
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Christian Lienhardt
- Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Emily A Kendall
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
2
|
Dartois V, Dick T. Therapeutic developments for tuberculosis and nontuberculous mycobacterial lung disease. Nat Rev Drug Discov 2024; 23:381-403. [PMID: 38418662 PMCID: PMC11078618 DOI: 10.1038/s41573-024-00897-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
Tuberculosis (TB) drug discovery and development has undergone nothing short of a revolution over the past 20 years. Successful public-private partnerships and sustained funding have delivered a much-improved understanding of mycobacterial disease biology and pharmacology and a healthy pipeline that can tolerate inevitable attrition. Preclinical and clinical development has evolved from decade-old concepts to adaptive designs that permit rapid evaluation of regimens that might greatly shorten treatment duration over the next decade. But the past 20 years also saw the rise of a fatal and difficult-to-cure lung disease caused by nontuberculous mycobacteria (NTM), for which the drug development pipeline is nearly empty. Here, we discuss the similarities and differences between TB and NTM lung diseases, compare the preclinical and clinical advances, and identify major knowledge gaps and areas of cross-fertilization. We argue that applying paradigms and networks that have proved successful for TB, from basic research to clinical trials, will help to populate the pipeline and accelerate curative regimen development for NTM disease.
Collapse
Affiliation(s)
- Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA.
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Thomas Dick
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Department of Microbiology and Immunology, Georgetown University, Washington, DC, USA
| |
Collapse
|
3
|
Osawa T, Watanabe M, Morimoto K, Yoshiyama T, Matsuda S, Fujiwara K, Furuuchi K, Shimoda M, Ito M, Kodama T, Uesugi F, Okumura M, Tanaka Y, Sasaki Y, Ogata H, Goto H, Kudoh S, Ohta K. Activities of Daily Living, Hypoxemia, and Lymphocytes Score for Predicting Mortality Risk in Patients With Pulmonary TB. Chest 2024; 165:267-277. [PMID: 37726072 DOI: 10.1016/j.chest.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND A clinically applicable mortality risk prediction system for pulmonary TB may improve treatment outcomes, but no easy-to-calculate and accurate score has yet been reported. The aim of this study was to construct a simple and objective disease severity score for patients with pulmonary TB. RESEARCH QUESTION Does a clinical score consisting of simple objective factors predict the mortality risk of patients with pulmonary TB? STUDY DESIGN AND METHODS The data set from our previous prospective study that recruited patients newly diagnosed with pulmonary TB was used for the development cohort. Patients for the validation cohort were prospectively recruited between March 2021 and September 2022. The primary end point was all-cause in-hospital mortality. Using Cox proportional hazards regression, a mortality risk prediction model was optimized in the development cohort. The disease severity score was developed by assigning integral points to each variate. RESULTS The data from 252 patients in the development cohort and 165 patients in the validation cohort were analyzed, of whom 39 (15.5%) and 17 (10.3%), respectively, died in the hospital. The disease severity score (named the AHL score) included three clinical parameters: activities of daily living (semi-dependent, 1 point; totally dependent, 2 points); hypoxemia (1 point), and lymphocytes (< 720/μL, 1 point). This score showed good discrimination with a C statistic of 0.902 in the development cohort and 0.842 in the validation cohort. We stratified the score into three groups (scores of 0, 1-2, and 3-4), which clearly corresponded to low (0% and 1.3%), intermediate (13.5% and 8.9%), and high (55.8% and 39.3%) mortality risk in the development and validation cohorts. INTERPRETATION The easy-to-calculate AHL disease severity score for patients with pulmonary TB was able to categorize patients into three mortality risk groups with great accuracy. CLINICAL TRIAL REGISTRATION University Hospital Medical Information Network Center; No. UMIN000012727 and No. UMIN000043849; URL: www.umin.ac.jp.
Collapse
Affiliation(s)
- Takeshi Osawa
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Masato Watanabe
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan.
| | - Kozo Morimoto
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan; Division of Clinical Research, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Takashi Yoshiyama
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan; Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Shuichi Matsuda
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Keiji Fujiwara
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Koji Furuuchi
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Masafumi Shimoda
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Masashi Ito
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Tatsuya Kodama
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Fumiko Uesugi
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Masao Okumura
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Yoshiaki Tanaka
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Yuka Sasaki
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Hideo Ogata
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Hajime Goto
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Shoji Kudoh
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Ken Ohta
- Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| |
Collapse
|
4
|
Bark CM, Boom WH, Furin JJ. More Tailored Approaches to Tuberculosis Treatment and Prevention. Annu Rev Med 2024; 75:177-188. [PMID: 37983385 DOI: 10.1146/annurev-med-100622-024848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Recent advances in the treatment of tuberculosis (TB) have led to improvements unprecedented in our lifetime. Decades of research in developing new drugs, especially for multidrug-resistant TB, have created not only multiple new antituberculous agents but also a new approach to development and treatment, with a focus on maximizing the benefit to the individual patient. Prevention of TB disease has also been improved and recognized as a critical component of global TB control. While the momentum is positive, it will take continued investment at all levels, especially training of new dedicated TB researchers and advocates around the world, to maintain this progress.
Collapse
Affiliation(s)
- Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA;
| | - W Henry Boom
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer J Furin
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Gupta-Wright A, den Boon S, MacLean EL, Cirillo D, Cobelens F, Gillespie SH, Kohli M, Ruhwald M, Savic R, Brigden G, Gidado M, Goletti D, Hanna D, Hasan R, Hewison C, Koura KG, Lienhardt C, Lungu P, McHugh TD, McKenna L, Scott C, Scriba T, Sekaggya-Wiltshire C, Kasaeva T, Zignol M, Denkinger CM, Falzon D. Target product profiles: tests for tuberculosis treatment monitoring and optimization. Bull World Health Organ 2023; 101:730-737. [PMID: 37961060 PMCID: PMC10630735 DOI: 10.2471/blt.23.290901] [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: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023] Open
Abstract
The World Health Organization has developed target product profiles containing minimum and optimum targets for key characteristics for tests for tuberculosis treatment monitoring and optimization. Tuberculosis treatment optimization refers to initiating or switching to an effective tuberculosis treatment regimen that results in a high likelihood of a good treatment outcome. The target product profiles also cover tests of cure conducted at the end of treatment. The development of the target product profiles was informed by a stakeholder survey, a cost-effectiveness analysis and a patient-care pathway analysis. Additional feedback from stakeholders was obtained by means of a Delphi-like process, a technical consultation and a call for public comment on a draft document. A scientific development group agreed on the final targets in a consensus meeting. For characteristics rated of highest importance, the document lists: (i) high diagnostic accuracy (sensitivity and specificity); (ii) time to result of optimally ≤ 2 hours and no more than 1 day; (iii) required sample type to be minimally invasive, easily obtainable, such as urine, breath, or capillary blood, or a respiratory sample that goes beyond sputum; (iv) ideally the test could be placed at a peripheral-level health facility without a laboratory; and (v) the test should be affordable to low- and middle-income countries, and allow wide and equitable access and scale-up. Use of these target product profiles should facilitate the development of new tuberculosis treatment monitoring and optimization tests that are accurate and accessible for all people being treated for tuberculosis.
Collapse
Affiliation(s)
- Ankur Gupta-Wright
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | - Saskia den Boon
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Emily L MacLean
- Central Clinical School, University of Sydney, Sydney, Australia
| | | | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam, Kingdom of the Netherlands
| | - Stephen H Gillespie
- Division of Infection and Global Health, University of St Andrews, St Andrews, Scotland
| | | | | | - Rada Savic
- University of California San Francisco, San Francisco, California, United States of America (USA)
| | - Grania Brigden
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases L Spallanzani-IRCCS, Rome, Italy
| | - Debra Hanna
- Bill & Melinda Gates Foundation, Seattle, USA
| | | | | | - Kobto G Koura
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Christian Lienhardt
- French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - Patrick Lungu
- East, Central and Southern Africa Health Community, Arusha, United Republic of Tanzania
| | - Timothy D McHugh
- Centre for Clinical Microbiology, University College London, London, England
| | | | | | | | | | - Tereza Kasaeva
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Matteo Zignol
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Claudia M Denkinger
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | - Dennis Falzon
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| |
Collapse
|
6
|
van Wijk RC, Imperial MZ, Savic RM, Solans BP. Pharmacokinetic analysis across studies to drive knowledge-integration: A tutorial on individual patient data meta-analysis (IPDMA). CPT Pharmacometrics Syst Pharmacol 2023; 12:1187-1200. [PMID: 37303132 PMCID: PMC10508576 DOI: 10.1002/psp4.13002] [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: 10/31/2022] [Revised: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023] Open
Abstract
Answering challenging questions in drug development sometimes requires pharmacokinetic (PK) data analysis across different studies, for example, to characterize PKs across diverse regions or populations, or to increase statistical power for subpopulations by combining smaller size trials. Given the growing interest in data sharing and advanced computational methods, knowledge integration based on multiple data sources is increasingly applied in the context of model-informed drug discovery and development. A powerful analysis method is the individual patient data meta-analysis (IPDMA), leveraging systematic review of databases and literature, with the most detailed data type of the individual patient, and quantitative modeling of the PK processes, including capturing heterogeneity of variance between studies. The methodology that should be used in IPDMA in the context of population PK analysis is summarized in this tutorial, highlighting areas of special attention compared to standard PK modeling, including hierarchical nested variability terms for interstudy variability, and handling between-assay differences in limits of quantification within a single analysis. This tutorial is intended for any pharmacological modeler who is interested in performing an integrated analysis of PK data across different studies in a systematic and thorough manner, to answer questions that transcend individual primary studies.
Collapse
Affiliation(s)
- Rob C. van Wijk
- University of California San Francisco Schools of Pharmacy and MedicineSan FranciscoCaliforniaUSA
- UCSF Center for Tuberculosis, University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Marjorie Z. Imperial
- University of California San Francisco Schools of Pharmacy and MedicineSan FranciscoCaliforniaUSA
- UCSF Center for Tuberculosis, University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Radojka M. Savic
- University of California San Francisco Schools of Pharmacy and MedicineSan FranciscoCaliforniaUSA
- UCSF Center for Tuberculosis, University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Belén P. Solans
- University of California San Francisco Schools of Pharmacy and MedicineSan FranciscoCaliforniaUSA
- UCSF Center for Tuberculosis, University of California San FranciscoSan FranciscoCaliforniaUSA
| |
Collapse
|
7
|
Ernest JP, Goh JJN, Strydom N, Wang Q, van Wijk RC, Zhang N, Deitchman A, Nuermberger E, Savic RM. Translational predictions of phase 2a first-in-patient efficacy studies for antituberculosis drugs. Eur Respir J 2023; 62:2300165. [PMID: 37321622 PMCID: PMC10469274 DOI: 10.1183/13993003.00165-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Phase 2a trials in tuberculosis typically use early bactericidal activity (EBA), the decline in sputum CFU over 14 days, as the primary end-point for testing the efficacy of drugs as monotherapy. However, the cost of phase 2a trials can range from USD 7 million to USD 19.6 million on average, while >30% of drugs fail to progress to phase 3. Better utilising pre-clinical data to predict and prioritise the most likely drugs to succeed will thus help to accelerate drug development and reduce costs. We aim to predict clinical EBA using pre-clinical in vivo pharmacokinetic (PK)-pharmacodynamic (PD) data and a model-based translational pharmacology approach. METHODS AND FINDINGS First, mouse PK, PD and clinical PK models were compiled. Second, mouse PK-PD models were built to derive an exposure-response relationship. Third, translational prediction of clinical EBA studies was performed using mouse PK-PD relationships and informed by clinical PK models and species-specific protein binding. Presence or absence of clinical efficacy was accurately predicted from the mouse model. Predicted daily decreases of CFU in the first 2 days of treatment and between day 2 and day 14 were consistent with clinical observations. CONCLUSION This platform provides an innovative solution to inform or even replace phase 2a EBA trials, to bridge the gap between mouse efficacy studies and phase 2b and phase 3 trials, and to substantially accelerate drug development.
Collapse
Affiliation(s)
- Jacqueline P Ernest
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Janice Jia Ni Goh
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Qianwen Wang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Rob C van Wijk
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Nan Zhang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Amelia Deitchman
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nuermberger
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
8
|
Motta I, Boeree M, Chesov D, Dheda K, Günther G, Horsburgh CR, Kherabi Y, Lange C, Lienhardt C, McIlleron HM, Paton NI, Stagg HR, Thwaites G, Udwadia Z, Van Crevel R, Velásquez GE, Wilkinson RJ, Guglielmetti L. Recent advances in the treatment of tuberculosis. Clin Microbiol Infect 2023:S1198-743X(23)00339-7. [PMID: 37482332 DOI: 10.1016/j.cmi.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Tuberculosis (TB) is a global health challenge and one of the leading causes of death worldwide. In the last decade, the TB treatment landscape has dramatically changed. After long years of stagnation, new compounds entered the market (bedaquiline, delamanid, and pretomanid) and phase III clinical trials have shown promising results towards shortening duration of treatment for both drug-susceptible (Study 31/A5349, TRUNCATE-TB, and SHINE) and drug-resistant TB (STREAM, NiX-TB, ZeNix, and TB-PRACTECAL). Dose optimization of rifamycins and repurposed drugs has also brought hopes of further development of safe and effective regimens. Consequently, international and WHO clinical guidelines have been updated multiple times in the last years to keep pace with these advances. OBJECTIVES This narrative review aims to summarize the state-of-the-art on treatment of drug-susceptible and drug-resistant TB, as well as recent trial results and an overview of ongoing clinical trials. SOURCES A non-systematic literature review was conducted in PubMed and MEDLINE, focusing on the treatment of TB. Ongoing clinical trials were listed according to the authors' knowledge and completed consulting clinicaltrials.gov and other publicly available websites (www.resisttb.org/clinical-trials-progress-report, www.newtbdrugs.org/pipeline/trials). CONTENT This review summarizes the recent, major changes in the landscape for drug-susceptible and drug-resistant treatment, with a specific focus on their potential impact on patient outcomes and programmatic TB management. Moreover, insights in host-directed therapies, and advances in pharmacokinetics and pharmacogenomics are discussed. A thorough outline of ongoing therapeutic clinical trials is presented, highlighting different approaches and goals in current TB clinical research. IMPLICATIONS Future research should be directed to individualize regimens and protect these recent breakthroughs by preventing and identifying the selection of drug resistance and providing widespread, affordable, patient-centred access to new treatment options for all people affected by TB.
Collapse
Affiliation(s)
- Ilaria Motta
- Médecins Sans Frontières, Manson Unit, London, United Kingdom
| | - Martin Boeree
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dumitru Chesov
- Chiril Draganiuc Phthisiopneumology Institute, Chisinau, Moldova; Department of Pulmonology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gunar Günther
- Department of Pulmonology and Allergology, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Medical Sciences, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Charles Robert Horsburgh
- Departments of Epidemiology, Biostatistics, Global Health and Medicine, Boston University, Boston, MA, United States
| | - Yousra Kherabi
- Infectious, and Tropical Diseases Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Department of International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Pediatrics-Global Immigrant, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Christian Lienhardt
- Department of Translational Research Applied to HIV and Infectious Diseases, Institut de Recherche pour le Développement, Montpellier, France; Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen M McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nicholas I Paton
- Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Helen R Stagg
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Zarir Udwadia
- Department of Internal Medicine and Pulmonology, Hinduja Hospital & Research Centre, Mumbai, India
| | - Reinout Van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Gustavo E Velásquez
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, United States; Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Robert J Wilkinson
- Francis Crick Institute, London, United Kingdom; Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Lorenzo Guglielmetti
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France; AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Laboratoire de Bactériologie-Hygiène, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France.
| |
Collapse
|
9
|
Solans BP, Imperial MZ, Olugbosi M, Savic RM. Analysis of Dynamic Efficacy Endpoints of the Nix-TB Trial. Clin Infect Dis 2023; 76:1903-1910. [PMID: 36804834 PMCID: PMC10249992 DOI: 10.1093/cid/ciad051] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Safer, better, and shorter treatments for multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) are an urgent global health need. The phase 3 clinical trial Nix-TB (NCT02333799) tested a 6-month treatment of MDR and XDR-TB consisting of high-dose linezolid, bedaquiline, and pretomanid (BPaL). In this study, we investigate the relationship between the pharmacokinetic characteristics of the drugs, patient characteristics and efficacy endpoints from Nix-TB. METHODS Pharmacokinetic data were collected at weeks 2, 8, and 16. Efficacy endpoints including treatment outcomes, time to stable culture conversion, and longitudinal time to positivity in the mycobacterial growth indicator tube assay were each characterized using nonlinear mixed-effects modeling. Relationships between patient, treatment pharmacokinetics, and disease characteristics and efficacy endpoints were evaluated. RESULTS Data from 93 (85% of the total) participants were analyzed. Higher body mass index was associated with a lower incidence of unfavorable treatment outcomes. Median time to stable culture conversion was 3 months in patients with lower baseline burden compared with 4.5 months in patients with high baseline burden. Participants with minimal disease had steeper time to positivity trajectories compared with participants with high-risk phenotypes. No relationship between any drugs' pharmacokinetics (drug concentration or exposure metrics) and any efficacy outcomes was observed. CONCLUSIONS We have successfully described efficacy endpoints of a BPaL regimen from the Nix-TB trial. Participants with high-risk phenotypes significantly delayed time to culture conversion and bacterial clearance. The lack of a relationship between pharmacokinetic exposures and pharmacodynamic biomarkers opens the possibility to use lower, safer doses, particularly for toxicity-prone linezolid. CLINICAL TRIALS REGISTRATION NCT02333799.
Collapse
Affiliation(s)
- Belén P Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | - Marjorie Z Imperial
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | | | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
10
|
Manika K, Loukeri A, Sionidou M, Moschos C, Papavasileiou A. Treatment for tuberculosis due to sensitive strains: To shorten or not to shorten? PNEUMON 2023. [DOI: 10.18332/pne/156697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
11
|
Chang V, Phillips PPJ, Imperial MZ, Nahid P, Savic RM. A comparison of clinical development pathways to advance tuberculosis regimen development. BMC Infect Dis 2022; 22:920. [PMID: 36494644 PMCID: PMC9733404 DOI: 10.1186/s12879-022-07846-w] [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: 04/21/2022] [Accepted: 11/04/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Current tuberculosis (TB) regimen development pathways are slow and in urgent need of innovation. We investigated novel phase IIc and seamless phase II/III trials utilizing multi-arm multi-stage and Bayesian response adaptive randomization trial designs to select promising combination regimens in a platform adaptive trial. METHODS Clinical trial simulation tools were built using predictive and validated parametric survival models of time to culture conversion (intermediate endpoint) and time to TB-related unfavorable outcome (final endpoint). This integrative clinical trial simulation tool was used to explore and optimize design parameters for aforementioned trial designs. RESULTS Both multi-arm multi-stage and Bayesian response adaptive randomization designs were able to reliably graduate desirable regimens in ≥ 95% of trial simulations and reliably stop suboptimal regimens in ≥ 90% of trial simulations. Overall, adaptive phase IIc designs reduced patient enrollment by 17% and 25% with multi-arm multi-stage and Bayesian response adaptive randomization designs respectively compared to the conventional sequential approach, while seamless designs reduced study duration by 2.6 and 3.5 years respectively (typically ≥ 8.5 years for standard sequential approach). CONCLUSIONS In this study, we demonstrate that adaptive trial designs are suitable for TB regimen development, and we provide plausible design parameters for a platform adaptive trial. Ultimately trial design and specification of design parameters will depend on clinical trial objectives. To support decision-making for clinical trial designs in contemporary TB regimen development, we provide a flexible clinical trial simulation tool that can be used to explore and optimize design features and parameters.
Collapse
Affiliation(s)
- V. Chang
- grid.266102.10000 0001 2297 6811Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA USA
| | - P. P. J. Phillips
- grid.266102.10000 0001 2297 6811UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA USA
| | - M. Z. Imperial
- grid.266102.10000 0001 2297 6811Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA USA
| | - P. Nahid
- grid.266102.10000 0001 2297 6811UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA USA
| | - R. M. Savic
- grid.266102.10000 0001 2297 6811Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA USA
| |
Collapse
|
12
|
Heyckendorf J, Georghiou SB, Frahm N, Heinrich N, Kontsevaya I, Reimann M, Holtzman D, Imperial M, Cirillo DM, Gillespie SH, Ruhwald M. Tuberculosis Treatment Monitoring and Outcome Measures: New Interest and New Strategies. Clin Microbiol Rev 2022; 35:e0022721. [PMID: 35311552 PMCID: PMC9491169 DOI: 10.1128/cmr.00227-21] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Despite the advent of new diagnostics, drugs and regimens, tuberculosis (TB) remains a global public health threat. A significant challenge for TB control efforts has been the monitoring of TB therapy and determination of TB treatment success. Current recommendations for TB treatment monitoring rely on sputum and culture conversion, which have low sensitivity and long turnaround times, present biohazard risk, and are prone to contamination, undermining their usefulness as clinical treatment monitoring tools and for drug development. We review the pipeline of molecular technologies and assays that serve as suitable substitutes for current culture-based readouts for treatment response and outcome with the potential to change TB therapy monitoring and accelerate drug development.
Collapse
Affiliation(s)
- Jan Heyckendorf
- Department of Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | | | - Nicole Frahm
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | - Irina Kontsevaya
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Maja Reimann
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - David Holtzman
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
| | - Marjorie Imperial
- University of California San Francisco, San Francisco, California, USA, United States
| | - Daniela M. Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stephen H. Gillespie
- School of Medicine, University of St Andrewsgrid.11914.3c, St Andrews, Fife, Scotland
| | - Morten Ruhwald
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
| | | |
Collapse
|
13
|
Gupta M, Srikrishna G, Klein SL, Bishai WR. Genetic and hormonal mechanisms underlying sex-specific immune responses in tuberculosis. Trends Immunol 2022; 43:640-656. [PMID: 35842266 PMCID: PMC9344469 DOI: 10.1016/j.it.2022.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
Abstract
Tuberculosis (TB), the world's deadliest bacterial infection, afflicts more human males than females, with a male/female (M/F) ratio of 1.7. Sex disparities in TB prevalence, pathophysiology, and clinical manifestations are widely reported, but the underlying biological mechanisms remain largely undefined. This review assesses epidemiological data on sex disparity in TB, as well as possible underlying hormonal and genetic mechanisms that might differentially modulate innate and adaptive immune responses in males and females, leading to sex differences in disease susceptibility. We consider whether this sex disparity can be extended to the efficacy of vaccines and discuss novel animal models which may offer mechanistic insights. A better understanding of the biological factors underpinning sex-related immune responses in TB may enable sex-specific personalized therapies for TB.
Collapse
|
14
|
Esmail H, Macpherson L, Coussens AK, Houben RMGJ. Mind the gap - Managing tuberculosis across the disease spectrum. EBioMedicine 2022; 78:103928. [PMID: 35339424 PMCID: PMC9044004 DOI: 10.1016/j.ebiom.2022.103928] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/22/2021] [Accepted: 02/24/2022] [Indexed: 11/18/2022] Open
Abstract
We currently have a binomial approach to managing tuberculosis. Those with active disease, ideally confirmed microbiologically, are treated with a standard 6-month, multi-drug regimen and those with latent infection and no evidence of disease with shorter, one or two drug regimens. Clinicians frequently encounter patients that fall between these two management pathways with some but not all features of disease and this will occur more often with the increasing emphasis on chest X-ray-based systematic screening. The view of tuberculosis as a spectrum of disease states is being increasingly recognised and is leading to new diagnostic approaches for early disease. However, the 6-month regimen for treating disease was driven by the duration required to treat the most extensive forms of pulmonary TB and shorter durations appear sufficient for less extensive disease. It is time undertake clinical trials to better define the optimal treatment for tuberculosis across the disease spectrum.
Collapse
Affiliation(s)
- Hanif Esmail
- MRC Clinical Trials Unit at University College London, UK; Institute for Global Health, University College London, UK; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.
| | | | - Anna K Coussens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Infectious Diseases and Immune Defense Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia; Department of Medical Biology, University of Melbourne, Parkville, Australia
| | - Rein M G J Houben
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| |
Collapse
|
15
|
Tuberkulose: Der Weg zu einer individuelleren Therapiedauer. Pneumologie 2022. [DOI: 10.1055/a-1697-9862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|