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Mahapatra A, Thiruvengadam K, Nair D, Padmapriyadarsini C, Thomas B, Pati S, Bulliyya G, Das D, Chowdhury J, Bang A, Swaminathan S. Effectiveness of food supplement on treatment outcomes and quality of life in pulmonary tuberculosis: Phased implementation approach. PLoS One 2024; 19:e0305855. [PMID: 39012889 PMCID: PMC11251611 DOI: 10.1371/journal.pone.0305855] [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: 05/13/2023] [Accepted: 06/05/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND By encouraging treatment adherence and lowering mortality, dietary supplements can serve as adjuvant therapy for the success of medical interventions. We determined the effect of locally accessible food supplements on treatment outcomes, and health-related quality of life in patients with pulmonary tuberculosis initiating anti-tuberculosis treatment (ATT) in Odisha, India. METHOD Between September 2017 and December 2018, implementation research in patients with newly diagnosed sputum smear-positive pulmonary tuberculosis initiating ATT in five districts of the tribal belt of Odisha, offered food supplements along with ATT in a phased manner. Clinical symptoms, anthropometry, sputum for M. tuberculosis (M. tb), health-related quality of life and return to normal function were assessed periodically, and favourable treatment outcome (cure or treatment completed) was measured at the end of treatment. The effect of the food supplement on unfavorable outcomes (treatment failure, death, or lost-to-follow-up) was modelled using mixed-effects Poisson regression to determine the risk factors. RESULTS Among the 761 participants enrolled, 614 participants received the food supplement and 147 did not receive the food supplement. Among the 614 participants in the supplement group, 537 (87%) had a favorable outcome and among the 147 participants in the no-supplement group, 113 (77%) had a favorable outcome (p = 0.0017). Higher age (>55 years) [aRR = 2.1(95% CI: 1.1-3.8)], male gender [aRR = 1.7(95% CI: 1.2-2.9)], and smear grading ≥2+ [aRR = 1.5 (95% CI: 1.1-2.2)] were associated with unfavorable treatment outcomes. Nutritional status, quality of life and lung health showed significant improvement from baseline in the supplement group. CONCLUSION Improvement in the nutritional status of the patient can be considered a predictor of treatment success rates. Early food supplementation has a positive impact on the nutritional status.
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Affiliation(s)
| | | | - Dina Nair
- ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | | | - Beena Thomas
- ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Sanghamitra Pati
- ICMR-Regional Medical Research Centre, Bhubaneswar, Odisha, India
| | - Gandham Bulliyya
- ICMR-Regional Medical Research Centre, Bhubaneswar, Odisha, India
| | - Dasarathi Das
- ICMR-Regional Medical Research Centre, Bhubaneswar, Odisha, India
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Wagnew F, Alene KA, Kelly M, Gray D. Undernutrition increases the risk of unsuccessful treatment outcomes of patients with tuberculosis in Ethiopia: A multicenter retrospective cohort study. J Infect 2024; 89:106175. [PMID: 38729526 DOI: 10.1016/j.jinf.2024.106175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND While undernutrition has been identified as a common risk factor for tuberculosis (TB), its impact on treatment outcomes has yet to be investigated in high TB burden and low-income countries such as Ethiopia. Therefore, this study aimed to investigate the effect of undernutrition on treatment outcomes among patients with TB in northwest Ethiopia. METHODS A retrospective cohort study was conducted using data from different hospitals in northwest Ethiopia, for the period from July 2017 to August 2023. A Cox proportional hazard model was performed to determine the effect of undernutrition on TB treatment outcomes, which were defined as a composite of death, treatment failure, or loss to follow-up. RESULTS A total of 602 patients with TB were included in the analysis. Of these, 367 (60.9%) were male, and 344 (57.1%) were undernourished. Upon completion of the follow-up period, 65 (10.8%) adults with TB had unsuccessful treatment outcomes. After adjusting for potential confounders, patients with undernutrition had a two times higher risk of experiencing unsuccessful treatment outcomes compared to well-nourished patients (AHR: 2.0, 95% CI: 1.2, 3.6). In addition, patients residing in rural areas (AHR: 3.1, 95% CI: 1.7, 5.4), having a history of prior TB treatment (AHR: 2.2, 95%CI: 1.1, 4.1), and the presence of diabetes comorbidity (AHR: 2.4, 95% CI: 1.1, 5.2) were at higher risk of unsuccessful treatment outcomes. CONCLUSIONS Undernutrition increases the risk of unsuccessful treatment outcomes in Ethiopia. This finding suggests that nutritional support during TB treatment can improve successful treatment outcomes in high TB burden and low-income countries such as Ethiopia.
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Affiliation(s)
- Fasil Wagnew
- National Centre for Epidemiology and Population Health (NCEPH), College of Health and Medicine, The Australian National University, Canberra, Australia; College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia; Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.
| | - Kefyalew Addis Alene
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, Western Australia, Australia; School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Matthew Kelly
- National Centre for Epidemiology and Population Health (NCEPH), College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Darren Gray
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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Thomas TA, Lukumay S, Yu S, Rao P, Siemiątkowska A, Kagan L, Augustino D, Mejan P, Mosha R, Handler D, Petros de Guex K, Mmbaga B, Pfaeffle H, Reiss R, Peloquin CA, Vinnard C, Mduma E, Xie YL, Heysell SK. Rifampin urinary excretion to predict serum targets in children with tuberculosis: a prospective diagnostic accuracy study. Arch Dis Child 2023; 108:616-621. [PMID: 37171408 PMCID: PMC10766442 DOI: 10.1136/archdischild-2022-325250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/13/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Pharmacokinetic variability drives tuberculosis (TB) treatment outcomes but measurement of serum drug concentrations for personalised dosing is inaccessible for children in TB-endemic settings. We compared rifampin urine excretion for prediction of a serum target associated with treatment outcome. DESIGN Prospective diagnostic accuracy study. SETTING Inpatient wards and outpatient clinics, northern Tanzania. PATIENTS Children aged 4-17 years were consecutively recruited on initiation of WHO-approved treatment regimens. INTERVENTIONS Samples were collected after directly observed therapy at least 2 weeks after initiation in the intensive phase: serum at pre-dose and 1, 2 and 6 hours post-dose, later analysed by liquid chromatography-tandem mass spectrometry for calculation of rifampin total exposure or area under the concentration time curve (AUC0-24); urine at post-dose intervals of 0-4, 4-8 and 8-24 hours, with rifampin excretion amount measured onsite by spectrophotometry. MAIN OUTCOME MEASURES Receiver operating characteristic (ROC) curve for percentage of rifampin dose excreted in urine measured by spectrophotometry to predict serum rifampin AUC0-24 target of 31.7 mg*hour/L. RESULTS 89 children, 52 (58%) female, with median age of 9.1 years, had both serum and urine collection. Only 59 (66%) reached the serum AUC0-24 target, reflected by a range of urine excretion patterns. Area under the ROC curve for percentage of rifampin dose excreted in urine over 24 hours predicting serum AUC0-24 target was 69.3% (95% CI 56.7% to 81.8%), p=0.007. CONCLUSIONS Urine spectrophotometry correlated with a clinically relevant serum target for rifampin, representing a step toward personalised dosing for children in TB-endemic settings.
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Affiliation(s)
- Tania A Thomas
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Saning'o Lukumay
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Sijia Yu
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Prakruti Rao
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Anna Siemiątkowska
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
- Pharmacy, Poznań University, Poznan, Poland
| | - Leonid Kagan
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Domitila Augustino
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Paulo Mejan
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Restituta Mosha
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Deborah Handler
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kristen Petros de Guex
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Blandina Mmbaga
- Department of Pediatrics, Kilimanjaro Christian Medical College, Moshi, Tanzania, United Republic of
| | - Herman Pfaeffle
- Department of Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Robert Reiss
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Christopher Vinnard
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Estomih Mduma
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Yingda L Xie
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Scott K Heysell
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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The effect of undernutrition on sputum culture conversion and treatment outcomes among people with multidrug-resistant tuberculosis: a systematic review and meta-analysis. Int J Infect Dis 2023; 127:93-105. [PMID: 36481489 DOI: 10.1016/j.ijid.2022.11.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the effect of undernutrition on sputum culture conversion and treatment outcomes among people with multidrug-resistant tuberculosis (MDR-TB). METHODS We searched for publications in the Medline, Embase, Scopus, and Web of Science databases. We conducted a random-effect meta-analysis to estimate the effects of undernutrition on sputum culture conversion and treatment outcomes. Hazard ratio (HR) for sputum culture conversion and odds ratio (OR) for end-of-treatment outcomes, with 95% CI, were used to summarize the effect estimates. Potential publication bias was checked using funnel plots and Egger's tests. RESULTS Of the 2358 records screened, 63 studies comprising a total of 31,583 people with MDR-TB were included. Undernutrition was significantly associated with a longer time to sputum culture conversion (HR 0.7, 95% CI 0.6-0.9, I2 = 67·1%), and a higher rate of mortality (OR 2.8, 95% CI 2.1-3.6, I2 = 21%) and unsuccessful treatment outcomes (OR 1.8, 95% CI 1.5-2.1, I2 = 70%). There was no significant publication bias in the included studies. CONCLUSION Undernutrition was significantly associated with unsuccessful treatment outcomes, including mortality and longer time to sputum culture conversion among people with MDR-TB. These findings have implications for supporting targeted nutritional interventions alongside standardized TB drugs.
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Tikiso T, McIlleron H, Abdelwahab MT, Bekker A, Hesseling A, Chabala C, Davies G, Zar HJ, Rabie H, Andrieux-Meyer I, Lee J, Wiesner L, Cotton MF, Denti P. Population pharmacokinetics of ethambutol in African children: a pooled analysis. J Antimicrob Chemother 2022; 77:1949-1959. [PMID: 35466379 PMCID: PMC9633720 DOI: 10.1093/jac/dkac127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/30/2022] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES Ethambutol protects against the development of resistance to co-administered drugs in the intensive phase of first-line anti-TB treatment in children. It is especially relevant in settings with a high prevalence of HIV or isoniazid resistance. We describe the population pharmacokinetics of ethambutol in children with TB to guide dosing in this population. METHODS We pooled data from 188 intensively sampled children from the DATiC, DNDi and SHINE studies, who received 15-25 mg/kg ethambutol daily according to WHO guidelines. The median (range) age and weight of the cohort were 1.9 (0.3-12.6) years and 9.6 (3.9-34.5) kg, respectively. Children with HIV (HIV+; n = 103) received ART (lopinavir/ritonavir in 92%). RESULTS Ethambutol pharmacokinetics were best described by a two-compartment model with first-order elimination and absorption transit compartments. Clearance was estimated to reach 50% of its mature value by 2 months after birth and 99% by 3 years. Typical steady-state apparent clearance in a 10 kg child was 15.9 L/h. In HIV+ children on lopinavir/ritonavir, bioavailability was reduced by 32% [median (IQR) steady-state Cmax = 0.882 (0.669-1.28) versus 1.66 (1.21-2.15) mg/L). In young children, bioavailability correlated with age. At birth, bioavailability was 73.1% of that in children 3.16 years or older. CONCLUSIONS To obtain exposure within the 2-6 mg/L recommended range for Cmax, the current doses must be doubled (or tripled with HIV+ children on lopinavir/ritonavir) for paediatric patients. This raises concerns regarding the potential for ocular toxicity, which would require evaluation.
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Affiliation(s)
- Tjokosela Tikiso
- 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
- 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
| | - Mahmoud Tareq Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrie Bekker
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Chishala Chabala
- University of Zambia, School of Medicine and Children’s Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Geraint Davies
- Malawi-Liverpool-Wellcome Research Unit, Blantyre, Malawi
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health and Family Centre for Research with Ubuntu (FAM-CRU), Stellenbosch University, Cape Town, South Africa
- Tygerberg Children’s Hospital, Cape Town, South Africa
| | | | - Janice Lee
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark F Cotton
- Department of Paediatrics and Child Health and Family Centre for Research with Ubuntu (FAM-CRU), Stellenbosch University, Cape Town, South Africa
- Tygerberg Children’s Hospital, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Fage D, Brilleman R, Deprez G, Payen MC, Cotton F. Development, validation and clinical use of a LC-MS/MS method for the simultaneous determination of the nine main antituberculosis drugs in human plasma. J Pharm Biomed Anal 2022; 215:114776. [DOI: 10.1016/j.jpba.2022.114776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/29/2022]
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Enteropathogen spectrum and effect on antimycobacterial pharmacokinetics among children with tuberculosis in rural Tanzania: a prospective cohort study. THE LANCET MICROBE 2022; 3:e408-e416. [PMID: 35659902 PMCID: PMC9174596 DOI: 10.1016/s2666-5247(21)00308-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 02/03/2023] Open
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Mendoza MA, Alshaer MH, Roldan G, Castro JG, Ashkin D, Peloquin CA, Boulanger CV. Effect of Rifabutin in Dolutegravir Dosing: A Case Series. J Int Assoc Provid AIDS Care 2022; 21:23259582221111077. [PMID: 36026587 PMCID: PMC9421219 DOI: 10.1177/23259582221111077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Tuberculosis (TB) is the leading cause of death in human immunodeficiency virus (HIV)-infected people worldwide. Currently there are no studies examining the use of Rifabutin (RBN) and Dolutegravir (DTG) in co-infected persons. This is a case series of 4 co-infected patients receiving both agents who underwent Pharmacokinetic (PK) analysis. Methods and Results: This is a retrospective chart review study of four patients diagnosed with both HIV and TB, receiving RBN and DTG and undergoing therapeutic drug monitoring. All 4 cases had lower than expected DTG concentrations at least once, including those on the current recommended dose of DTG with RBN, and even those receiving higher doses. Conclusions: Given the frequency of low DTG and RBN concentrations, therapeutic drug monitoring (TDM) for these drugs is advisable. Prospective clinical studies are needed to further determine the PK interactions between RBN and DTG, and virologic response to treatment.
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Affiliation(s)
- Maria A Mendoza
- Department of Medicine, University of Miami, Miami, FL, USA.,Department of Infectious Diseases, 12235Mayo Clinic, Rochester, MN, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy, and Emerging Pathogens Institute, 3463University of Florida, Miami, FL, USA
| | | | - Jose Guillermo Castro
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Ashkin
- Bureau of Communicable Diseases, 7824TB Control Section Florida Department of Health, Tallahassee, FL, USA
| | - Charles A Peloquin
- Bureau of Communicable Diseases, 7824TB Control Section Florida Department of Health, Tallahassee, FL, USA
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Sinha P, Lönnroth K, Bhargava A, Heysell SK, Sarkar S, Salgame P, Rudgard W, Boccia D, Van Aartsen D, Hochberg NS. Food for thought: addressing undernutrition to end tuberculosis. THE LANCET. INFECTIOUS DISEASES 2021; 21:e318-e325. [PMID: 33770535 PMCID: PMC8458477 DOI: 10.1016/s1473-3099(20)30792-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 07/18/2020] [Accepted: 09/04/2020] [Indexed: 01/15/2023]
Abstract
Tuberculosis is the leading cause of deaths from an infectious disease worldwide. WHO's End TB Strategy is falling short of several 2020 targets. Undernutrition is the leading population-level risk factor for tuberculosis. Studies have consistently found that undernutrition is associated with increased tuberculosis incidence, increased severity, worse treatment outcomes, and increased mortality. Modelling studies support implementing nutritional interventions for people living with tuberculosis and those at risk of tuberculosis disease to ensure the success of the End TB Strategy. In this Personal View, we highlight nutrition-related immunocompromisation, implications of undernutrition for tuberculosis treatment and prevention, the role of nutritional supplementation, pharmacokinetics and pharmacodynamics of antimycobacterial medications in undernourished people with tuberculosis, and the role of social protection interventions in addressing undernutrition as a tuberculosis risk factor. To catalyse action on this insufficiently addressed accelerant of the global tuberculosis epidemic, research should be prioritised to understand the immunological pathways that are impaired by nutrient deficiencies, develop tools to diagnose clinical and subclinical tuberculosis in people who are undernourished, and understand how nutritional status affects the efficacy of tuberculosis vaccine and therapy. Through primary research, modelling, and implementation research, policy change should also be accelerated, particularly in countries with a high burden of tuberculosis.
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Affiliation(s)
- Pranay Sinha
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston University, MA, USA.
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anurag Bhargava
- Department of Medicine, Yenepoya Medical College, and Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, India; Department of Medicine, McGill University, Montreal, QC, Canada
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, VA, USA
| | - Sonali Sarkar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Padmini Salgame
- Center for Emerging Pathogens, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - William Rudgard
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Delia Boccia
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Daniel Van Aartsen
- Division of Infectious Diseases and International Health, University of Virginia, VA, USA
| | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston University, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston University, MA, USA
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Abstract
Tuberculosis (TB) remains an infectious disease of global significance and a
leading cause of death in low- and middle-income countries. Significant effort
has been directed towards understanding Mycobacterium
tuberculosis genomics, virulence, and pathophysiology within the
framework of Koch postulates. More recently, the advent of “-omics” approaches
has broadened our appreciation of how “commensal” microbes have coevolved with
their host and have a central role in shaping health and susceptibility to
disease. It is now clear that there is a diverse repertoire of interactions
between the microbiota and host immune responses that can either sustain or
disrupt homeostasis. In the context of the global efforts to combatting TB, such
findings and knowledge have raised important questions: Does microbiome
composition indicate or determine susceptibility or resistance to
M. tuberculosis infection? Is the
development of active disease or latent infection upon M.
tuberculosis exposure influenced by the microbiome? Does
microbiome composition influence TB therapy outcome and risk of reinfection with
M. tuberculosis? Can the microbiome be
actively managed to reduce risk of M.
tuberculosis infection or recurrence of TB? Here, we
explore these questions with a particular focus on microbiome-immune
interactions that may affect TB susceptibility, manifestation and progression,
the long-term implications of anti-TB therapy, as well as the potential of the
host microbiome as target for clinical manipulation.
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Affiliation(s)
- Giorgia Mori
- The University of Queensland Diamantina Institute, Faculty
of Medicine, The University of Queensland, Brisbane, Australia
| | - Mark Morrison
- The University of Queensland Diamantina Institute, Faculty
of Medicine, The University of Queensland, Brisbane, Australia
| | - Antje Blumenthal
- The University of Queensland Diamantina Institute, Faculty
of Medicine, The University of Queensland, Brisbane, Australia
- * E-mail:
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Abubakar M, Ahmad N, Ghafoor A, Latif A, Ahmad I, Atif M, Saleem F, Khan S, Khan A, Khan AH. Treatment Outcomes of Extensively Drug-Resistant Tuberculosis in Pakistan: A Countrywide Retrospective Record Review. Front Pharmacol 2021; 12:640555. [PMID: 33867989 PMCID: PMC8044444 DOI: 10.3389/fphar.2021.640555] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The current study is conducted with the aim to the fill the gap of information regarding treatment outcomes and variables associated with unsuccessful outcome among XDR-TB patients from Pakistan. Methods: A total of 404 culture confirmed XDR-TB patients who received treatment between 1st May 2010 and June 30, 2017 at 27 treatment centers all over Pakistan were retrospectively followed until their treatment outcomes were reported. A p-value <0.05 reflected a statistical significant association. Results: The patients had a mean age 32.9 ± 14.1 years. The overall treatment success rate was 40.6% (95% confidence interval [CI]:35.80-45.60%). A total of 155 (38.4%) patients were declared cured, 9 (2.2%) completed treatment, 149 (36.9%) died, 60 (14.9%) failed treatment and 31 (7.7%) were lost to follow up (LTFU). The results of the multivariate binary logistic regression analysis revealed that the patients' age of >60 years (OR = 4.69, 95%CI:1.57-15.57) and receiving high dose isoniazid (OR = 2.36, 95%CI:1.14-4.85) had statistically significant positive association with death, whereas baseline body weight >40 kg (OR = 0.43, 95%CI:0.25-0.73) and sputum culture conversion in the initial two months of treatment (OR = 0.33, 95%CI:0.19-0.58) had statistically significant negative association with death. Moreover, male gender had statistically significant positive association (OR = 1.92, 95%CI:1.04-3.54) with LTFU. Conclusion: The treatment success rate (40.6%) of XDR-TB patients in Pakistan was poor. Providing special attention and enhanced clinical management to patients with identified risk factors for death and LTFU in the current cohort may improve the treatment outcomes.
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Affiliation(s)
- Muhammad Abubakar
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Nafees Ahmad
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Abdul Ghafoor
- MDR-TB Specialist, National TB Control Program, Islamabad, Pakistan
| | - Abdullah Latif
- Data Manager, National AIDS, TB and Malaria Control Program, Islamabad, Pakistan
| | - Izaz Ahmad
- Department of Biology, Syed Babar Ali School of Science and Engineering, Lahore University of Management Sciences, Lahore, Pakistan
| | - Muhammad Atif
- Department of Pharmacy Practice, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Fahad Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | | | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, Penang, Malaysia
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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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Evaluation of super-boosted lopinavir/ritonavir in combination with rifampicin in HIV-1-infected patients with tuberculosis. Int J Antimicrob Agents 2019; 55:105840. [PMID: 31704214 DOI: 10.1016/j.ijantimicag.2019.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/17/2019] [Accepted: 10/26/2019] [Indexed: 11/21/2022]
Abstract
Rifampicin induces the metabolism of many drugs. To overcome the reduction in serum concentrations of lopinavir/ritonavir (LPV/r) when used in combination with rifampicin, 800/200 mg or 400/400 mg doses are used. This study evaluated super-boosted LPV/r (400/400 mg) in HIV/TB co-infected patients for adequate concentrations as well as short-term safety, tolerability and clinical response to therapy. This was an open-label, non-randomised pharmacokinetic (PK) study in HIV/TB patients. The primary objective was to determine the PK profile of super-boosted LPV/r when given with a rifampicin-based TB regimen. Secondary objectives were short-term safety, tolerability and clinical response. Primary endpoints were a lopinavir trough concentration (Cmin) >1.0 µg/mL and a rifampicin maximum concentration (Cmax) of 8-24 µg/mL. Secondary PK endpoints were a rifampicin area under the concentration-time curve from 0-24 h (AUC0-24) of 44-70 µg·h/mL, a lopinavir Cmax of 6-14 µg/mL and a lopinavir AUC0-12 of 56-130 µg·h/mL. Eleven patients (10 male, age 25-43 years) were enrolled. Two patients were discontinued due to non-compliance. A lopinavir Cmin of >1.0 µg/mL was achieved in a least one of the PK samplings in all nine subjects who completed treatment. All patients met lopinavir Cmax and AUC0-12 targets. Five patients achieved the primary endpoint of rifampicin Cmax (≥8 µg/mL) in at least one of the PK samplings, and five achieved the minimum rifampicin AUC0-24 (≥44 µg·h/mL). One grade 3 adverse event was reported. Super-boosted LPV/r was safe and effective in HIV/TB patients. [ClinicalTrials.gov ID NCT01700790.].
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Golichenari B, Nosrati R, Farokhi-Fard A, Faal Maleki M, Gheibi Hayat SM, Ghazvini K, Vaziri F, Behravan J. Electrochemical-based biosensors for detection of Mycobacterium tuberculosis and tuberculosis biomarkers. Crit Rev Biotechnol 2019; 39:1056-1077. [DOI: 10.1080/07388551.2019.1668348] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Behrouz Golichenari
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rahim Nosrati
- Cellular and Molecular Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Aref Farokhi-Fard
- Medical Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran, Iran
| | - Mahdi Faal Maleki
- Department of Pharmaceutical Chemistry, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Kiarash Ghazvini
- Department of Microbiology and Virology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzam Vaziri
- Microbiology Research Center (MRC), Pasteur Institute of Iran, Tehran, Iran
- Center for Bioengineering and Biotechnology, University of Waterloo, Waterloo, Canada
| | - Javad Behravan
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Center for Bioengineering and Biotechnology, University of Waterloo, Waterloo, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Canada
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McIlleron H, Chirehwa MT. Current research toward optimizing dosing of first-line antituberculosis treatment. Expert Rev Anti Infect Ther 2018; 17:27-38. [PMID: 30501530 PMCID: PMC6364307 DOI: 10.1080/14787210.2019.1555031] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Drug concentrations in tuberculosis patients on standard regimens vary widely with clinically important consequences. Areas covered: We review the available literature identifying factors correlated with pharmacokinetic variability of antituberculosis drugs. Based on population pharmacokinetic models and the weight, height, and sex distributions in a large data base of African tuberculosis patients, we propose simplified weight-based doses of the available fixed dose combination(FDC) for adults with drug susceptible tuberculosis. Emerging studies will support optimized weight-based dosing for children. Other sources of important pharmacokinetic variability include genetic variants, drug-drug interactions, formulation quality, and methods of preparation and administration. Expert commentary: Optimized weight band-based dosing will result in more equitable distribution of drug exposures by weight. The use of high doses of isoniazid in patients with drug-resistant tuberculosis would be safer and more effective if a feasible test was developed to allow stratified dosing according to acetylator type. There is an urgent need for more suitable formulations of many second-line drugs for children. The adoption of new technologies and efficient FDC design may allow further advances for patients and treatment programs. Lastly, current efforts to ensure adequate quality of antituberculosis drug products are not preventing the use of substandard products to treat patients with tuberculosis.
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Affiliation(s)
- Helen McIlleron
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
| | - Maxwell T Chirehwa
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
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Justine M, Yeconia A, Nicodemu I, Augustino D, Gratz J, Mduma E, Heysell SK, Kivuyo S, Mfinanga S, Peloquin CA, Zagurski T, Kibiki GS, Mmbaga B, Houpt ER, Thomas TA. Pharmacokinetics of First-Line Drugs Among Children With Tuberculosis in Rural Tanzania. J Pediatric Infect Dis Soc 2018; 9:14-20. [PMID: 30395239 PMCID: PMC7317157 DOI: 10.1093/jpids/piy106] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/17/2018] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dosing recommendations for treating childhood tuberculosis (TB) were revised by the World Health Organization, yet so far, pharmacokinetic studies that have evaluated these changes are relatively limited. We evaluated plasma drug concentrations of rifampicin (RIF), isoniazid (INH), pyrazinamide (PZA), and ethambutol (EMB) among children undergoing TB treatment in Tanzania when these dosing recommendations were being implemented. METHODS At the end of intensive-phase TB therapy, blood was obtained 2 hours after witnessed medication administration to estimate the peak drug concentration (C2h), measured using high-performance liquid chromatography or liquid chromatography-tandem mass spectrometry methods. Differences in median drug concentrations were compared on the basis of the weight-based dosing strategy using the Mann-Whitney U test. Risk factors for low drug concentrations were analyzed using multivariate regression analysis. RESULTS We enrolled 51 human immunodeficiency virus-negative children (median age, 5.3 years [range, 0.75-14 years]). The median C2hs were below the target range for each TB drug studied. Compared with children who received the "old" dosages, those who received the "revised" WHO dosages had a higher median C2h for RIF (P = .049) and PZA (P = .015) but not for INH (P = .624) or EMB (P = .143); however, these revised dosages did not result in the target range for RIF, INH, and EMB being achieved. A low starting dose was associated with a low C2h for RIF (P = .005) and PZA (P = .005). Malnutrition was associated with a low C2h for RIF (P = .001) and INH (P = .001). CONCLUSIONS Among this cohort of human immunodeficiency virus-negative Tanzanian children, use of the revised dosing strategy for treating childhood TB did not result in the target drug concentration for RIF, INH, or EMB being reached.
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Affiliation(s)
- Museveni Justine
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Anita Yeconia
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Ingi Nicodemu
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Domitila Augustino
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Jean Gratz
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Estomih Mduma
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Sokoine Kivuyo
- National Institute of Medical Research Muhimbili, Dar es Salaam, Tanzania
| | - Sayoki Mfinanga
- National Institute of Medical Research Muhimbili, Dar es Salaam, Tanzania
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetic Laboratory, University of Florida, Gainesville
| | - Theodore Zagurski
- Infectious Disease Pharmacokinetic Laboratory, University of Florida, Gainesville
| | - Gibson S Kibiki
- East African Health Research Commission, East African Community, Arusha, Tanzania
| | - Blandina Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville,Correspondence: T. A. Thomas, MD, MPH, University of Virginia, Division of Infectious Diseases and International Health, PO Box 801340, Charlottesville, VA 22908 ()
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17
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Vinnard C, Ravimohan S, Tamuhla N, Pasipanodya J, Srivastava S, Modongo C, Zetola NM, Weissman D, Gumbo T, Bisson GP. Markers of gut dysfunction do not explain low rifampicin bioavailability in HIV-associated TB. J Antimicrob Chemother 2018; 72:2020-2027. [PMID: 28472448 DOI: 10.1093/jac/dkx111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/13/2017] [Indexed: 11/12/2022] Open
Abstract
Background Rifampicin is the key drug responsible for sterilizing activities in the first-line TB treatment regimen. Damage to the gut during acute and chronic HIV infection may inhibit drug absorptive capacity. We sought to test the hypothesis that markers of intestinal damage, bacterial translocation and systemic immune activation would relate to rifampicin bioavailability among HIV/TB patients. Patients and methods We conducted a prospective cohort study of rifampicin pharmacokinetics in HIV/TB patients in Gaborone, Botswana. We performed two intensively sampled pharmacokinetic visits, before and after ART initiation. Non-linear mixed-effects modelling was performed to determine whether variability in markers of gut damage, microbial translocation or systemic immune activation contributed to variability in rifampicin bioavailability before and after the initiation of ART. Results We enrolled 40 HIV/TB patients in the first pharmacokinetic visit and 24 patients returned for the second pharmacokinetic visit after initiating ART. Low rifampicin exposure, as defined by the maximum serum concentration, was observed in 40% of patients prior to initiating ART and 46% of patients after initiating ART. In the non-linear mixed-effects model, we did not observe significant covariate effects of markers of gut damage, microbial translocation or immune activation on rifampicin bioavailability before and after ART initiation. Discussion Markers of intestinal damage, microbial translocation and systemic immune activation did not explain variability in rifampicin bioavailability. The a priori identification of HIV/TB patients at risk for low rifampicin concentrations remains a challenge, supporting a role for therapeutic drug monitoring during HIV/TB therapy.
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Affiliation(s)
- Christopher Vinnard
- Public Health Research Institute, Rutgers, The State University of New Jersey, 225 Warren Street, Newark, NJ 07103, USA
| | - Shruthi Ravimohan
- University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Neo Tamuhla
- Botswana-UPenn Partnership, 214 Independence Avenue, Gaborone, Botswana
| | - Jotam Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, 3434 Live Oak Street, Dallas, TX 75204, USA
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, 3434 Live Oak Street, Dallas, TX 75204, USA
| | - Chawangwa Modongo
- Botswana-UPenn Partnership, 214 Independence Avenue, Gaborone, Botswana
| | - Nicola M Zetola
- Botswana-UPenn Partnership, 214 Independence Avenue, Gaborone, Botswana
| | - Drew Weissman
- University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, 3434 Live Oak Street, Dallas, TX 75204, USA
| | - Gregory P Bisson
- University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA 19104, USA
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Malikowski T, Mahmood M, Smyrk T, Raffals L, Nehra V. Tuberculosis of the gastrointestinal tract and associated viscera. J Clin Tuberc Other Mycobact Dis 2018; 12:1-8. [PMID: 31720391 PMCID: PMC6830173 DOI: 10.1016/j.jctube.2018.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 03/10/2018] [Accepted: 04/09/2018] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis involvement of the gastrointestinal tract, peritoneum, and associated viscera is an uncommon but well described entity. While peritoneal tuberculosis and tuberculous enteritis are more common, involvement of the esophagus, stomach, colon, rectum, anus, liver, bile ducts, gallbladder, and pancreas can occur. Diagnosis is challenging as cases often mimic neoplasm or inflammatory bowel disease. In this review we outline the pathogenesis, clinical presentation, diagnostic testing, and treatment strategies pertaining to such cases.
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Affiliation(s)
- Thomas Malikowski
- Department of Internal Medicine, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Maryam Mahmood
- Division of Infectious Diseases, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Thomas Smyrk
- Department of Anatomic Pathology, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Vandana Nehra
- Division of Gastroenterology and Hepatology, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
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A Pilot Study of Immune Activation and Rifampin Absorption in HIV-Infected Patients without Tuberculosis Infection: A Short Report. Tuberc Res Treat 2017; 2017:2140974. [PMID: 29430306 PMCID: PMC5752984 DOI: 10.1155/2017/2140974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/18/2017] [Accepted: 11/01/2017] [Indexed: 11/18/2022] Open
Abstract
Background Rifampin malabsorption is frequently observed in tuberculosis patients coinfected with human immunodeficiency virus (HIV) but cannot be predicted by patient factors such as CD4+ T cell count or HIV viral load. Methods We sought to describe the relationship between HIV-associated immune activation, measures of gut absorptive capacity and permeability, and rifampin pharmacokinetic parameters in a pilot study of 6 HIV-infected, tuberculosis-uninfected patients who were naïve to antiretroviral therapy. Results The median rifampin area under the concentration-versus-time curve during the 8-hour observation period was 42.8 mg·hr/L (range: 21.2 to 57.6), with a median peak concentration of 10.1 mg/L (range: 5.3 to 12.5). We observed delayed rifampin absorption, with a time to maximum concentration greater than 2 hours, in 2 of 6 participants. There was a trend towards increased plasma concentrations of sCD14, a marker of monocyte activation in response to bacterial translocation, among participants with delayed rifampin absorption compared to participants with rapid absorption (p = 0.06). Conclusions Delayed rifampin absorption may be associated with elevated markers of bacterial translocation among HIV-infected individuals naïve to antiretroviral therapy. This trial is registered with NCT01845298.
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20
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Clinical Pharmacokinetics of Rifampin in Patients with Tuberculosis and Type 2 Diabetes Mellitus: Association with Biochemical and Immunological Parameters. Antimicrob Agents Chemother 2015; 59:7707-14. [PMID: 26438503 DOI: 10.1128/aac.01067-15] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/25/2015] [Indexed: 12/25/2022] Open
Abstract
Tuberculosis (TB) remains a major public health issue due to the increasing incidence of type 2 diabetes mellitus (T2DM), which exacerbates the clinical course of TB and increases the risk of poor long-term outcomes. The aim of this study was to characterize the pharmacokinetics of rifampin (RIF) and its relationship with biochemical and immunological parameters in patients with TB and T2DM. The biochemical and immunological parameters were assessed on the same day that the pharmacokinetic evaluation of RIF was performed. Factors related to the metabolic syndrome that is characteristic of T2DM patients were not detected in the TB-T2DM group (where predominant malnutrition was present) or in the TB group. Percentages of CD8(+) T lymphocytes and NK cells were diminished in the TB and TB-T2DM patients, who had high tumor necrosis factor alpha (TNF-α) and low interleukin-17 (IL-17) levels compared to healthy volunteers. Delayed RIF absorption was observed in the TB and TB-T2DM patients; absorption was poor and slower in the latter group due to poor glycemic control. RIF clearance was also slower in the diabetic patients, thereby prolonging the mean residence time of RIF. There was a significant association between glycemic control, increased TNF-α serum concentrations, and RIF pharmacokinetics in the TB-T2DM patients. These altered metabolic and immune conditions may be factors to be considered in anti-TB therapy management when TB and T2DM are concurrently present.
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21
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Svensson EM, Murray S, Karlsson MO, Dooley KE. Rifampicin and rifapentine significantly reduce concentrations of bedaquiline, a new anti-TB drug. J Antimicrob Chemother 2014; 70:1106-14. [PMID: 25535219 PMCID: PMC4356204 DOI: 10.1093/jac/dku504] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives Bedaquiline is the first drug of a new class approved for the treatment of TB in decades. Bedaquiline is metabolized by cytochrome P450 (CYP) 3A4 to a less-active M2 metabolite. Its terminal half-life is extremely long (5–6 months), complicating evaluations of drug–drug interactions. Rifampicin and rifapentine, two anti-TB drugs now being optimized to shorten TB treatment duration, are potent inducers of CYP3A4. This analysis aimed to predict the effect of repeated doses of rifampicin or rifapentine on the steady-state pharmacokinetics of bedaquiline and its M2 metabolite from single-dose data using a model-based approach. Methods Pharmacokinetic data for bedaquiline and M2 were obtained from a Phase I study involving 32 individuals each receiving two doses of bedaquiline, alone or together with multiple-dose rifampicin or rifapentine. Sampling was performed over 14 days following each bedaquiline dose. Pharmacokinetic analyses were performed using non-linear mixed-effects modelling. Models were used to simulate potential dose adjustments. Results Rifamycin co-administration increased bedaquiline clearance substantially: 4.78-fold [relative standard error (RSE) 9.10%] with rifampicin and 3.96-fold (RSE 5.00%) with rifapentine. Induction of M2 clearance was equally strong. Average steady-state concentrations of bedaquiline and M2 are predicted to decrease by 79% and 75% when given with rifampicin or rifapentine, respectively. Simulations indicated that increasing the bedaquiline dosage to mitigate the interaction would yield elevated M2 concentrations during the first treatment weeks. Conclusions Rifamycin antibiotics reduce bedaquiline concentrations substantially. In line with current treatment guidelines for drug-susceptible TB, concomitant use is not recommended, even with dose adjustment.
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Affiliation(s)
- Elin M Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, PO Box 591, 751 24 Uppsala, Sweden
| | - Stephen Murray
- Department of Clinical Research, Global Alliance for TB Drug Development, New York, NY, USA
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, PO Box 591, 751 24 Uppsala, Sweden
| | - Kelly E Dooley
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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McLeay SC, Vis P, van Heeswijk RPG, Green B. Population pharmacokinetics of bedaquiline (TMC207), a novel antituberculosis drug. Antimicrob Agents Chemother 2014; 58:5315-24. [PMID: 24957842 PMCID: PMC4135833 DOI: 10.1128/aac.01418-13] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 06/18/2014] [Indexed: 01/28/2023] Open
Abstract
Bedaquiline is a novel agent for the treatment of pulmonary multidrug-resistant Mycobacterium tuberculosis infections, in combination with other agents. The objective of this study was to develop a population pharmacokinetic (PK) model for bedaquiline to describe the concentration-time data from phase I and II studies in healthy subjects and patients with drug-susceptible or multidrug-resistant tuberculosis (TB). A total of 5,222 PK observations from 480 subjects were used in a nonlinear mixed-effects modeling approach. The PK was described with a 4-compartment disposition model with dual zero-order input (to capture dual peaks observed during absorption) and long terminal half-life (t1/2). The model included between-subject variability on apparent clearance (CL/F), apparent central volume of distribution (Vc/F), the fraction of dose via the first input, and bioavailability (F). Bedaquiline was widely distributed, with apparent volume at steady state of >10,000 liters and low clearance. The long terminal t1/2 was likely due to redistribution from the tissue compartments. The final covariate model adequately described the data and had good simulation characteristics. The CL/F was found to be 52.0% higher for subjects of black race than that for subjects of other races, and Vc/F was 15.7% lower for females than that for males, although their effects on bedaquiline exposure were not considered to be clinically relevant. Small differences in F and CL/F were observed between the studies. The residual unexplained variability was 20.6% and was higher (27.7%) for long-term phase II studies.
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Affiliation(s)
| | - Peter Vis
- Janssen Infectious Diseases BVBA, Beerse, Belgium
| | | | - Bruce Green
- Model Answers Pty Ltd., Brisbane, Queensland, Australia
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Medellín-Garibay SE, Milán-Segovia RDC, Magaña-Aquino M, Portales-Pérez DP, Romano-Moreno S. Pharmacokinetics of rifampicin in Mexican patients with tuberculosis and healthy volunteers. ACTA ACUST UNITED AC 2014; 66:1421-8. [PMID: 24841364 DOI: 10.1111/jphp.12275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/30/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to compare the pharmacokinetics (PK) of rifampicin (RIF) between healthy volunteers and patients with tuberculosis (TB). METHODS RIF was administered as a single 600-mg dose to 24 healthy volunteers and 24 TB patients, followed by serial blood sampling. Plasma concentrations were analysed using a chromatographic method, and the PK parameters were estimated using WinNonlin software. KEY FINDINGS Peak plasma concentration ranged from 6.4 to 19.9 mg/l, which was subtherapeutic for 15% of the study participants in both groups, mostly in men (71.4%). The mean area under the concentration-time curve (AUC0-24h ) did not show differences between these groups (P > 0.05). The absorption rate was slower in TB patients and the volume of distribution normalized by total body weight (Vd/kg) was greater than healthy volunteers (P < 0.05). A greater Vd and clearance were found in male subjects. The lag time (tlag) and the time before reach Cmax (Tmax) were longer for female TB patients (P < 0.05). CONCLUSION The main differences in PK parameters of RIF between Mexican TB patients and healthy volunteers were demonstrated in absorption and distribution processes. In addition, differences in PK parameters observed by sex should be considered for further dosing recommendations.
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Nutritional supplementation increases rifampin exposure among tuberculosis patients coinfected with HIV. Antimicrob Agents Chemother 2014; 58:3468-74. [PMID: 24709267 DOI: 10.1128/aac.02307-13] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Nutritional supplementation to tuberculosis (TB) patients has been associated with increased weight and reduced mortality, but its effect on the pharmacokinetics of first-line anti-TB drugs is unknown. A cohort of 100 TB patients (58 men; median age, 35 [interquartile range {IQR}, 29 to 40] years, and median body mass index [BMI], 18.8 [17.3 to 19.9] kg/m(2)) were randomized to receive nutritional supplementation during the intensive phase of TB treatment. Rifampin plasma concentrations were determined after 1 week and 2 months of treatment. The effects of nutritional supplementation, HIV, time on treatment, body weight, and SLCO1B1 rs4149032 genotype were examined using a population pharmacokinetic model. The model adjusted for body size via allometric scaling, accounted for clearance autoinduction, and detected an increase in bioavailability (+14%) for the patients in the continuation phase. HIV coinfection in patients not receiving the supplementation was found to decrease bioavailability by 21.8%, with a median maximum concentration of drug in serum (Cmax) and area under the concentration-time curve from 0 to 24 h (AUC0-24) of 5.6 μg/ml and 28.6 μg · h/ml, respectively. HIV-coinfected patients on nutritional supplementation achieved higher Cmax and AUC0-24 values of 6.4 μg/ml and 31.6 μg · h/ml, respectively, and only 13.3% bioavailability reduction. No effect of the SLCO1B1 rs4149032 genotype was observed. In conclusion, nutritional supplementation during the first 2 months of TB treatment reduces the decrease in rifampin exposure observed in HIV-coinfected patients but does not affect exposure in HIV-uninfected patients. If confirmed in other studies, the use of defined nutritional supplementation in HIV-coinfected TB patients should be considered in TB control programs. (This study has the controlled trial registration number ISRCTN 16552219.).
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Hair Analysis for Determination of Isoniazid Concentrations and Acetylator Phenotype during Antituberculous Treatment. Tuberc Res Treat 2012; 2012:327027. [PMID: 23091716 PMCID: PMC3469096 DOI: 10.1155/2012/327027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 09/03/2012] [Accepted: 09/04/2012] [Indexed: 11/17/2022] Open
Abstract
Background. Analysis of isoniazid (INH) uptake has been based on measurement of plasma concentrations providing a short-term and potentially biased view. Objectives. To establish hair analysis as a tool to measure long-term uptake of INH and to assess whether acetylator phenotype in hair reflects N-acetyltransferase-2 (NAT2) genotype. Design and Methods. INH and acetyl-INH concentrations in hair were determined in patients on INH treatment for M. tuberculosis infection using high pressure liquid chromatography/mass spectrometry. Acetyl-INH/INH ratios were correlated with NAT-2 genotype. Results. Hair concentrations of INH, determined in 40 patients, were not dependent on ethnic group or body mass index and were significantly higher in male compared to female patients (median (range) 2.37 ng/mg (0.76–4.9) versus 1.11 ng/mg (0.02–7.20) (P = 0.02). Acetyl-INH/INH ratios were a median of 15.2% (14.5 to 31.7) in homozygous rapid acetylator NAT-2 genotype and 37.3% (1.73 to 51.2) in the heterozygous rapid acetylator NAT-2 genotype and both significantly higher than in the slow acetylator NAT-2 genotype with 5.8% (0.53 to 14.4) (P < 0.05).
Conclusions. Results of hair analysis for INH showed lower concentrations in females. Acetyl-INH/INH ratios were significantly lower in patients with slow acetylator versus rapid acetylator genotypes.
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Pharmacokinetics of isoniazid, rifampin, and pyrazinamide in children younger than two years of age with tuberculosis: evidence for implementation of revised World Health Organization recommendations. Antimicrob Agents Chemother 2011; 55:5560-7. [PMID: 21968358 DOI: 10.1128/aac.05429-11] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The World Health Organization (WHO) recently issued revised first-line antituberculosis (anti-TB) drug dosage recommendations for children. No pharmacokinetic studies for these revised dosages are available for children <2 years. The aim of the study was to document the pharmacokinetics of the first-line anti-TB agents in children <2 years of age comparing previous and revised WHO dosages of isoniazid (INH; 5 versus 10 mg/kg/day), rifampin (RMP; 10 versus 15 mg/kg/day), and pyrazinamide (PZA; 25 versus 35 mg/kg/day) and to investigate the effects of clinical covariates, including HIV coinfection, nutritional status, age, gender, and type of tuberculosis (TB), and the effect of NAT2 acetylator status. Serum INH, PZA, and RMP levels were prospectively assessed in 20 children <2 years of age treated for TB following the previous and the revised WHO dosage recommendations. Samples were taken prior to dosing and at 0.5, 1.5, 3, and 5 h following dosing. The maximum drug concentration in serum (C(max)), the time to C(max) (t(max)), and the area under the concentration-time curve (AUC) were calculated. Eleven children had pulmonary and 9 had extrapulmonary TB. Five were HIV infected. The mean C(max) (μg/ml) following the administration of previous/revised dosages were as follows: INH, 3.19/8.11; RMP, 6.36/11.69; PZA, 29.94/47.11. The mean AUC (μg·h/ml) were as follows: INH, 8.09/20.36; RMP, 17.78/36.95; PZA, 118.0/175.2. The mean C(max) and AUC differed significantly between doses. There was no difference in the t(max) values achieved. Children less than 2 years of age achieve target concentrations of first-line anti-TB agents using revised WHO dosage recommendations. Our data provided supportive evidence for the implementation of the revised WHO guidelines for first-line anti-TB therapy in young children.
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Donald PR, Maritz JS, Diacon AH. The pharmacokinetics and pharmacodynamics of rifampicin in adults and children in relation to the dosage recommended for children. Tuberculosis (Edinb) 2011; 91:196-207. [PMID: 21429802 DOI: 10.1016/j.tube.2011.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 02/07/2011] [Accepted: 02/08/2011] [Indexed: 11/29/2022]
Abstract
The dosages of antituberculosis agents recommended for treatment of childhood tuberculosis often reflect those for adult patients with similar mg/kg body weight dosages and ranges advised. Literature relating to the pharmacokinetics and pharmacodynamics of rifampicin (RMP) is reviewed and the serum concentrations reached by adults, both patients and healthy volunteers and children, established or not established on RMP, compared. Straight line regression of maximum RMP serum concentrations (C(max)) on dosage, weighted for the number of individuals, found slopes (SE) of 1.025 (0.067) and 0.881 (0.046) respectively for adult volunteers not established and established on RMP (P = 0.076), and similarly 0.748 (0.057) and 0.684 (0.038) respectively for adult patients (P < 0.001) and 0.622 (0.050) and 0.368 (0.041) respectively for children (P < 0.001). These results indicate that for equivalent RMP dosages adult patients reach a lower C(max) than adult volunteers and that adults, both volunteers and patients established on RMP reach higher C(max) values than children; children established on RMP require approximately twice the mg/kg body weight dosage of RMP to reach serum concentrations equivalent to those of adults. It is noteworthy that many adult patients receiving currently recommended RMP dosages also do not reach the often recommended RMP 2 h serum concentration of 8 μg/mL.
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Affiliation(s)
- P R Donald
- Department of Paediatrics and Child Health and Tygerberg Children's Hospital, Faculty of Health Sciences, Stellenbosch University, South Africa.
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Bento J, Duarte R, Brito MC, Leite S, Lobato MR, Caldeira MDC, Carvalho A. Malabsorption of antimycobacterial drugs as a cause of treatment failure in tuberculosis. BMJ Case Rep 2010; 2010:2010/sep23_1/bcr1220092554. [PMID: 22778380 DOI: 10.1136/bcr.12.2009.2554] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Malabsorption of oral antimycobacterial drugs is a rare cause of treatment failure in tuberculosis (TB). Several predisposing comorbidities have been recognised. HIV infection is the most important risk factor referred in the literature. There are few reports about antimycobacterial drugs malabsorption, particularly in the absence of predisposing comorbidities. The authors present a clinical case of oral treatment failure in TB due to malabsorption; however, what caused the failure remained unclear. Possible causes of malabsorption are discussed under various sections. Purpose of this case report is to point to this rare situation that can easily go unnoticed unless a very high level of suspicion is present.
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Affiliation(s)
- João Bento
- Department of Pulmonology, Hospital de S Joao, Alameda Professor Hernani Monteiro, Porto, Portugal.
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Effects of tuberculosis, race, and human gene SLCO1B1 polymorphisms on rifampin concentrations. Antimicrob Agents Chemother 2010; 54:4192-200. [PMID: 20660695 DOI: 10.1128/aac.00353-10] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rifampin has concentration-dependent activity against Mycobacterium tuberculosis. However, marked intersubject variation of rifampin concentrations occurs. In this study, we evaluated rifampin pharmacokinetics in relation to tuberculosis, geographic region, race, and single nucleotide polymorphisms of the human transporter genes SLCO1B1, SLCO1B3, and MDR1. Seventy-two adults with pulmonary tuberculosis from Africa, North America, and Spain were evaluated during multidrug intensive-phase therapy, and their results were compared to those from 16 healthy controls from North America. Rifampin pharmacokinetic values were similar between tuberculosis patients and controls (geometric mean [GM] area under the concentration-time curve from 0 to 24 h [AUC(0-24)] of 40.2 versus 40.9 μg.h/ml; P = 0.9). However, in multivariable analyses, the rifampin AUC(0-24) was significantly affected by rifampin dosage (in mg/kg of body weight), polymorphisms in the SLCO1B1 gene, and the presence of tuberculosis by geographic region. The adjusted rifampin AUC(0-24) was lowest in patients with tuberculosis from Africa compared to that in non-African patients or control subjects. The adjusted rifampin AUC(0-24) was also 36% lower among participants with SLCO1B1 genotype c.463CA than that among participants with SLCO1B1 genotype c.463CC (adjusted GM, 29.8 versus 46.7 μg.h/ml; P = 0.001). Polymorphisms in the SLCO1B1 gene associated with lower rifampin exposure were more frequent among black subjects. In conclusion, marked intersubject variation of the rifampin AUC(0-24) values was observed, but the mean values of the AUC(0-24) did not significantly vary between patients with tuberculosis and healthy controls. Lower rifampin exposure was associated with the polymorphism of the SLCO1B1 c.463C>A gene. When adjusted for the patient mg/kg dosage and transporter gene polymorphisms, rifampin exposure was lower in patients with tuberculosis, which suggests that additional absorption or metabolic processes affect rifampin exposure with tuberculosis disease.
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Sosnik A, Carcaboso ÁM, Glisoni RJ, Moretton MA, Chiappetta DA. New old challenges in tuberculosis: potentially effective nanotechnologies in drug delivery. Adv Drug Deliv Rev 2010; 62:547-59. [PMID: 19914315 DOI: 10.1016/j.addr.2009.11.023] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Accepted: 09/14/2009] [Indexed: 10/20/2022]
Abstract
Tuberculosis (TB) is the second most deadly infectious disease. Despite potentially curative pharmacotherapies being available for over 50 years, the length of the treatment and the pill burden can hamper patient lifestyle. Thus, low compliance and adherence to administration schedules remain the main reasons for therapeutic failure and contribute to the development of multi-drug-resistant (MDR) strains. Pediatric patients constitute a high risk population. Most of the first-line drugs are not commercially available in pediatric form. The design of novel antibiotics attempts to overcome drug resistance, to shorten the treatment course and to reduce drug interactions with antiretroviral therapies. On the other hand, the existing anti-TB drugs are still effective. Overcoming technological drawbacks of these therapeutic agents as well as improving the effectiveness of the drug by targeting the infection reservoirs remains the central aims of Pharmaceutical Technology. In this framework, nanotechnologies appear as one of the most promising approaches for the development of more effective and compliant medicines. The present review thoroughly overviews the state-of-the-art in the development of nano-based drug delivery systems for encapsulation and release of anti-TB drugs and discusses the challenges that are faced in the development of a more effective, compliant and also affordable TB pharmacotherapy.
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Lee SH, Oh T, Jeon BY, Kwak EY, Shim WS, Cho SN, Kim DD, Chung SJ, Shim CK. Tissue-specific changes in mRNA expression of Abc and Slc transporters in murine pulmonary tuberculosis. Xenobiotica 2009; 39:738-48. [DOI: 10.1080/00498250903089829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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