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Xing Y, Yin L, Le X, Chen J, Zhang L, Li Y, Lu H, Zhang L. Simultaneous determination of first-line anti-tuberculosis drugs and one metabolite of isoniazid by liquid chromatography/tandem mass spectrometry in patients with human immunodeficiency virus-tuberculosis coinfection. Heliyon 2021; 7:e07532. [PMID: 34296020 PMCID: PMC8282971 DOI: 10.1016/j.heliyon.2021.e07532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/14/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022] Open
Abstract
The incidence rate of tuberculosis (TB) in patients with human immunodeficiency virus (HIV) infection is 26 times higher than that in other patients. Patients with both infections require long-term combination therapy, which increases therapy complexity and might lead to serious adverse reactions and drug-drug interactions. To optimize therapy for patients with HIV and TB coinfection, we developed an ultra-high-performance liquid chromatography/tandem mass spectrometry (UHPLC-MS/MS) method to simultaneously quantify four anti-tuberculosis drugs and one isoniazid (INH) metabolite. Blood samples (n = 32) from 16 patients with HIV and TB coinfection were collected. Plasma protein precipitation with acetonitrile was followed by a hydrazine reaction between INH and cinnamaldehyde (CA) to produce phenylhydrazone (CA-INH) and dilution with heptafluorobutyric acid. The separation was performed on an Acquity UHPLC HSS T3 1.8 μm column (2.1 × 100 mm, Waters) with a mobile phase consisting of 10 mmol/L ammonium formate (pH = 4) in water (solvent A) and 0.1 % formic acid in methanol (solvent B) in a gradient elution. The compounds were detected using a positive multiple reaction monitoring model. INH, acetyl-INH (AC-INH), rifampicin (RIF), ethambutol (EMB), and pyrazinamide (PZA) showed good linear relationships in their quantitative ranges, with lower limits of quantification of 48, 192, 200, 96, and 480 ng/mL, respectively. The inter- and intraday precision was within 15 %, and the accuracy was between 85 % and 115 %. The mean plasma concentrations of INH, AC-INH, RIF, EMB, and PZA in patients were 1990.23 (24–16 600), 863.06 (96–2880), 3507.05 (229–9800), 808.10 (149–2130), and 18 838.33 (240–34 800) ng/mL, respectively. The plasma concentrations detected in the 16 patients were lower than the targeted concentrations in HIV-negative TB patients. In summary, we developed a simple UHPLC-MS/MS method for simultaneous quantification of first-line TB drugs, and successfully applied it for therapeutic drug monitoring in patients with HIV and TB coinfection. This method will facilitate monitoring of TB drugs in the future.
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Affiliation(s)
- Yaru Xing
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China.,Guilin Medical University, Guilin 541004, China
| | - Lin Yin
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Xiaoqin Le
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Jun Chen
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Lin Zhang
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Yingying Li
- Guilin Medical University, Guilin 541004, China
| | - Hongzhou Lu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Lijun Zhang
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
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Reckers A, Huo S, Esmail A, Dheda K, Bacchetti P, Gandhi M, Metcalfe J, Gerona R. Development and validation of a liquid chromatography-tandem mass spectrometry method for quantifying delamanid and its metabolite in small hair samples. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1169:122467. [PMID: 33713954 DOI: 10.1016/j.jchromb.2020.122467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/30/2020] [Accepted: 11/19/2020] [Indexed: 11/28/2022]
Abstract
New all-oral regimens for rifampin-resistant tuberculosis (RR-TB) are being scaled up globally. Measurement of drug concentrations in hair assesses long-term drug exposure. Delamanid (DLM) is likely to be a key component of future RR-TB treatment regimens, but a method to describe its quantification in hair via liquid chromatography-tandem mass spectrometry (LC-MS/MS) has not previously been described. We developed and validated a simple, fast, sensitive, and accurate LC-MS/MS method for quantifying DLM and its metabolite DM-6705 in small hair samples. We pulverized and extracted two milligrams of hair in methanol at 37 °C for two hours, and diluted 1:1 with water. A gradient elution method eluted DLM, DM-6705, and the internal standard OPC 14714 within 3 min, bringing overall analysis time to 5.5 min. The method has limits of detection (LOD) of 0.0003 ng/mg for DLM and 0.003 ng/mg for DM-6705. The established linear dynamic ranges are 0.003-2.1 ng/mg and 0.03-21 ng/mg for DLM and DM-6705, respectively. Eleven of 12 participant hair samples had concentrations within DLM's linear dynamic range, while all 12 samples had concentrations within the quantifiable range for DM-6705. The ranges of concentrations observed in these clinical samples for DLM and DM-6705 were 0.004-0.264 ng/mg hair and 0.412-12.041 ng/mg hair respectively. We demonstrate that while DLM was detected in hair at very low levels, its primary metabolite DM-6705 had levels approximately 100 times higher. Measuring DM-6705 in hair may accurately reflect long-term adherence to DLM-containing regimens for drug-resistant TB.
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Affiliation(s)
- Andrew Reckers
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), United States
| | - Stella Huo
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF, United States
| | - Ali Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, UCSF, United States
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, UCSF, United States
| | - John Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF, United States.
| | - Roy Gerona
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), United States.
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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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Predictors of Adverse TB Treatment Outcome among TB/HIV Patients Compared with Non-HIV Patients in the Greater Accra Regional Hospital from 2008 to 2016. Tuberc Res Treat 2020; 2020:1097581. [PMID: 32832153 PMCID: PMC7424490 DOI: 10.1155/2020/1097581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/13/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction The convergence of TB and HIV dual epidemics is a major public health challenge in Ghana as well as many developing countries. Treatment outcome monitoring is a vital part of the surveillance needed to successfully eliminate TB. The impact of HIV status and demographic and treatment-related factors on adverse TB treatment outcome has not been studied in the Greater Accra Regional Hospital. This study determined factors associated with TB treatment outcome in patients with TB-HIV coinfection and TB-only infection in the hospital. Method A cross-sectional study was carried out in the Greater Accra Regional Hospital. We reviewed TB treatment cards of patients who received treatment for tuberculosis in the hospital from 2008 to 2016. Data on treatment outcome and sociodemographic and clinical characteristics were extracted on TB-only-infected and TB/HIV-coinfected patients. The chi-squared test and binary and multiple logistic regression models were used to assess factors associated with adverse treatment outcome. Results Out of the 758 patient records analyzed, 174 (22.9%) were TB-HIV-coinfected patients. Overall treatment success for all TB patients was 88.1% (668/758). About 11.9% (90/758) of the patients had an adverse treatment outcome, including treatment failure 0.9% (7/758), defaulting 0.9% (7/758), and death 10.0% (76/758). TB-HIV-coinfected patients' treatment success was 78.1% (136/174). TB-only patients' treatment success was 91.4% (532/582). Independent predictors of adverse treatment outcome were found to be as follows: being HIV positive (aOR: 3.85, 95% CI: 2.19-6.75; p < 0.01); aged 65 and above (aOR: 1.76, 95% CI: 1.44-1.54; p = 0.01); and previously failed TB treatment (aOR: 5.02, 95% CI: 2.09-28.87; p < 0.01). Conclusion Treatment outcome for TB-HIV-coinfected patients is below the WHO target. HIV status, age, and category of patient of the TB patients were associated with adverse treatment outcome. Strengthening the TB/HIV collaborative efforts by stakeholders is required for good treatment outcomes.
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Kouanda S, Ouedraogo HG, Cisse K, Compaoré TR, Sulis G, Diagbouga S, Roggi A, Tarnagda G, Villani P, Sangare L, Simporé J, Regazzi M, Matteelli A. Pharmacokinetic study of two different rifabutin doses co-administered with lopinavir/ritonavir in African HIV and tuberculosis co-infected adult patients. BMC Infect Dis 2020; 20:449. [PMID: 32590942 PMCID: PMC7318514 DOI: 10.1186/s12879-020-05169-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background This study aimed to assess the pharmacokinetic profile of 150 mg rifabutin (RBT) taken every other day (every 48 h) versus 300 mg RBT taken every other day (E.O.D), both in combination with lopinavir/ritonavir (LPV/r), in adult patients with human immunodeficiency virus (HIV) and tuberculosis (TB) co-infection. Methods This is a two-arm, open-label, pharmacokinetic, randomised study conducted in Burkina Faso between May 2013 and December 2015. Enrolled patients were randomised to receive either 150 mg RBT EOD (arm A, 9 subjects) or 300 mg RBT EOD (arm B, 7 subjects), both associated with LPV/r taken twice daily. RBT plasma concentrations were evaluated after 2 weeks of combined HIV and TB treatment. Samples were collected just before drug ingestion and at 1, 2, 3, 4, 6, 8, and 12 h after drug ingestion to measure plasma drug concentration using an HPLC-MS/MS assay. Results The Cmax and AUC0–12h medians in arm A (Cmax = 296 ng/mL, IQR: 205–45; AUC0–12h = 2528 ng.h/mL, IQR: 1684–2735) were lower than those in arm B (Cmax = 600 ng/mL, IQR: 403–717; AUC0–12h = 4042.5 ng.h/mL, IQR: 3469–5761), with a statistically significant difference in AUC0–12h (p = 0.044) but not in Cmax (p = 0.313). No significant differences were observed in Tmax (3 h versus 4 h). Five patients had a Cmax below the plasma therapeutic limit (< 300 ng/mL) in the 150 mg RBT arm, while the Cmax was above this threshold for all patients in the 300 mg RBT arm. Additionally, at 48 h after drug ingestion, all patients had a mycobacterial minimum inhibitory concentration (MIC) above the limit (> 64 ng/mL) in the 300 mg RBT arm, while 4/9 patients had such values in the 150 mg RBT arm. Conclusion This study confirmed that the 150 mg dose of rifabutin ingested EOD in combination with LPV/r is inadequate and could lead to selection of rifamycin-resistant mycobacteria. Trial registration PACTR201310000629390, 28th October 2013.
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Affiliation(s)
- Seni Kouanda
- Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, 03BP7192, Burkina Faso.
| | - Henri Gautier Ouedraogo
- Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, 03BP7192, Burkina Faso
| | - Kadari Cisse
- Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, 03BP7192, Burkina Faso
| | - Tegwinde Rebeca Compaoré
- Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, 03BP7192, Burkina Faso
| | - Giorgia Sulis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Serge Diagbouga
- Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, 03BP7192, Burkina Faso
| | - Alberto Roggi
- Institute of Infectious and Tropical Diseases, Brescia University Hospital, Brescia, Italy
| | - Grissoum Tarnagda
- Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, 03BP7192, Burkina Faso
| | - Paola Villani
- Institute of Pharmacology, IRCCS, San Matteo University Hospital, Pavia, Italy
| | - Lassana Sangare
- Yalgado Ouedraogo University Teaching Hospital, Ouagadougou, Burkina Faso
| | - Jacques Simporé
- Centre de Recherche Biomoléculaire Pietro Annigoni (CERBA), Ouagadougou, Burkina Faso
| | - Mario Regazzi
- Institute of Pharmacology, IRCCS, San Matteo University Hospital, Pavia, Italy
| | - Alberto Matteelli
- Institute of Infectious and Tropical Diseases, Brescia University Hospital, Brescia, Italy
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Osei E, Oppong S, Der J. Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: A retrospective cohort study. PLoS One 2020; 15:e0234878. [PMID: 32579568 PMCID: PMC7313972 DOI: 10.1371/journal.pone.0234878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/03/2020] [Indexed: 12/23/2022] Open
Abstract
Background In an era of renewed commitment to accelerate the declines in Tuberculosis (TB) incidence and mortality, there is the need for National Tuberculosis Programmes (NTPs) to monitor trends in key indicators across a geographical location and to provide reliable data for direct measurement of TB incidence and mortality. In this context, we explored the trends of TB case detection, mortality and HIV co-infection, and examined the predictors of TB deaths in Ten districts of the Volta region of Ghana. Methods We conducted a retrospective cohort study of all TB cases registered from 2013 to 2017 in 10 districts of the Volta Region of Ghana. Case detection rate (CDR) was computed as the ratio of the number of new and relapse TB case notified to NTP to the number of estimated incident TB cases in a given year. Case fatality rates were estimated using data from 2012–2016 cohort of TB patients. Simple and multiple logistic regression were used to identify predictors of TB deaths with odds ratios and 95% confidence intervals estimated. Results Overall, there were 3,735 new and relapse TB patients who commenced anti-TB treatment during the period, representing the case detection rate of 40.1% with district variations. The CDR remained stable during the 5 years. Of the total cases, HIV status was documented for 3,144 (84.2%), among whom, 712 (22.6%) were HIV positive. The TB/HIV co-infection was more prevalent among children under 15 years of age (30.1%), males (30.6%), treatment after lost to follow-up patients (33.3%), and smear-negative pulmonary TB patients (29.1%). The prevalence of TB/HIV co-infection did not significantly change over the years. The overall case fatality rate was 13% (n = 486), with considerable variation among HIV-positives and HIV-negative TB patients (21.8% and 11% respectively) (p<0.001) and among districts. TB/HIV co-infection, sputum smear-negative pulmonary TB and district of anti-TB treatment predicted TB mortality. Conclusion TB case detection rate was low and remained stable during the study period, whereas co-infection with HIV and mortality rates were quite high, indicating the need for feasible strategies such as active case finding to improve case detection, and improved case management to reduce mortality.
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Affiliation(s)
- Eric Osei
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
- Department of Public Health Graduate School, Yonsei University, Seoul, Republic of Korea
- * E-mail:
| | - Samuel Oppong
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Joyce Der
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
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Osei E, Oppong S, Adanfo D, Doepe BA, Owusu A, Kupour AG, Der J. Reflecting on tuberculosis case notification and treatment outcomes in the Volta region of Ghana: a retrospective pool analysis of a multicentre cohort from 2013 to 2017. Glob Health Res Policy 2019; 4:37. [PMID: 31890895 PMCID: PMC6916450 DOI: 10.1186/s41256-019-0128-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a petrified condition with a huge economic and health impact on families and health systems in Ghana. Monitoring of TB programme performance indicators can provide reliable data for direct measurement of TB incidence and mortality. This study reflects on the trends of TB case notification and treatment outcomes and makes comparison among 10 districts of the Volta region of Ghana. METHODS This was a retrospective analysis of surveillance data of a cohort of TB cases from 2013 to 2017. Trends of case notification and treatment outcomes were examined and compared. Logistic regression was used to determine the independent relationship between patients and disease characteristics and unsuccessful treatment outcomes. Odds ratios, 95% confidence intervals and p-values were estimated. RESULTS A gradual declining trend of case notification of all forms of TB was noticed, with an overall case notification rate (CNR) of 65 cases per 100,000 population during the period. A wide variation of case notification of TB was observed among the districts, ranging from 32 to 124 cases per 100,000 population. Similarly, treatment success rate decreased slightly from 83.1% during the first year to 80.2% in 2017, with an overall treatment success rate of 82.5% (95% CI: 81.3-83.8%). Treatment failure, death, and lost to follow up rates were 0.8% (range 0.5-1.2%), 13.5% (range 12.4-14.7%), and 3.1% (range 2.6-3.8%) respectively. The treatment success rate among districts ranged from 70.5% in South Tongu to 90.8% in Krachi West district. Returned after treatment interruption (Adjusted odds ratio [AOR]: 3.62; 95% CI: 1.66-7.91; P < 0.001) and TB/HIV co-infection (AOR: 1.94; 95% CI: 1.57-2.40; P < 0.001) predicts poor treatment outcomes. CONCLUSION Over the past five years, TB case notification and successful treatment outcomes did not significantly improve. Wide district variations in CNR was observed. The overall treatment success rate observed in this study is below the target of > 90% set by the World Health Organization's (WHO) end TB strategy. Additionally, patients who returned to continue treatment after interruption and those who were co-infected with HIV strongly predict unsuccessful treatment outcomes. Sustained interventions to prevent treatment interruptions and improved management of co-morbidities can enhance treatment outcomes, as required to achieve the elimination goal.
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Affiliation(s)
- Eric Osei
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Samuel Oppong
- Department of Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Daniel Adanfo
- Department of Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Bless Ativor Doepe
- Department of Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Andrews Owusu
- Department of Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Augustine Goma Kupour
- Department of Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Joyce Der
- Department of Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
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Stott KE, Pertinez H, Sturkenboom MGG, Boeree MJ, Aarnoutse R, Ramachandran G, Requena-Méndez A, Peloquin C, Koegelenberg CFN, Alffenaar JWC, Ruslami R, Tostmann A, Swaminathan S, McIlleron H, Davies G. Pharmacokinetics of rifampicin in adult TB patients and healthy volunteers: a systematic review and meta-analysis. J Antimicrob Chemother 2019; 73:2305-2313. [PMID: 29701775 PMCID: PMC6105874 DOI: 10.1093/jac/dky152] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/31/2018] [Indexed: 12/29/2022] Open
Abstract
Objectives The objectives of this study were to explore inter-study heterogeneity in the pharmacokinetics (PK) of orally administered rifampicin, to derive summary estimates of rifampicin PK parameters at standard dosages and to compare these with summary estimates for higher dosages. Methods A systematic search was performed for studies of rifampicin PK published in the English language up to May 2017. Data describing the Cmax and AUC were extracted. Meta-analysis provided summary estimates for PK parameter estimates at standard rifampicin dosages. Heterogeneity was assessed by estimation of the I2 statistic and visual inspection of forest plots. Summary AUC estimates at standard and higher dosages were compared graphically and contextualized using preclinical pharmacodynamic (PD) data. Results Substantial heterogeneity in PK parameters was evident and upheld in meta-regression. Treatment duration had a significant impact on the summary estimates for rifampicin PK parameters, with Cmax 8.98 mg/L (SEM 2.19) after a single dose and 5.79 mg/L (SEM 2.14) at steady-state dosing, and AUC 72.56 mg·h/L (SEM 2.60) and 38.73 mg·h/L (SEM 4.33) after single and steady-state dosing, respectively. Rifampicin dosages of at least 25 mg/kg are required to achieve plasma PK/PD targets defined in preclinical studies. Conclusions Vast inter-study heterogeneity exists in rifampicin PK parameter estimates. This is not explained by the available modifying variables. The recommended dosage of rifampicin should be increased to improve efficacy. This study provides an important point of reference for understanding rifampicin PK at standard dosages as efforts to explore higher dosing strategies continue in this field.
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Affiliation(s)
- K E Stott
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - H Pertinez
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M J Boeree
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - G Ramachandran
- Department of Biochemistry and Clinical Pharmacology, National Institute for Research in Tuberculosis, Chennai, India
| | - A Requena-Méndez
- CRESIB, Barcelona Institute for Global Health, University of Barcelona, Barcelona, Spain
| | - C Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - C F N Koegelenberg
- Department of Pulmonology, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa
| | - J W C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - R Ruslami
- Department of Pharmacology and Therapy, Universitas Padjadjaran, Bandung, Indonesia
| | - A Tostmann
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S Swaminathan
- Indian Council of Medical Research, New Delhi, India
| | - H McIlleron
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - G Davies
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Institute of Global Health, University of Liverpool, Liverpool, UK
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Metcalfe J, Bacchetti P, Gerona R, Esmail A, Dheda K, Gandhi M. Association of anti-tuberculosis drug concentrations in hair and treatment outcomes in MDR- and XDR-TB. ERJ Open Res 2019; 5:00046-2019. [PMID: 31041318 PMCID: PMC6484095 DOI: 10.1183/23120541.00046-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 11/05/2022] Open
Abstract
Therapeutic drug monitoring for drug-resistant tuberculosis (TB) is likely to improve treatment outcomes. While assessments of plasma drug levels can explain pharmacokinetic variability among trial participants, these measures require phlebotomy and a cold chain, and are generally not repeated frequently enough to characterise drug exposure over time. Using a novel multi-analyte assay, we found evidence that higher anti-TB drug concentrations in hair, a non-biohazardous and noninvasively collected biomatrix, predict extensively-drug resistant-TB clinical outcomes in a high-burden setting.
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Affiliation(s)
- John Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, USA
| | - Peter Bacchetti
- Dept of Epidemiology and Biostatistics, University of California, UCSF, San Francisco, CA, USA
| | - Roy Gerona
- Maternal-Fetal Medicine Division, Dept of Obstetrics, Gynecology and Reproductive Sciences, University of California, UCSF, San Francisco, CA, USA
| | - Ali Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Dept of Medicine, University of California, UCSF, San Francisco, CA, USA
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Sin JH, Elshaboury RH, Hurtado RM, Letourneau AR, Gandhi RG. Therapeutic drug monitoring of antitubercular agents for disseminated Mycobacterium tuberculosis during intermittent haemodialysis and continuous venovenous haemofiltration. J Clin Pharm Ther 2017; 43:291-295. [PMID: 28895161 DOI: 10.1111/jcpt.12630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/23/2017] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE There is a lack of data regarding therapeutic drug monitoring (TDM) of antitubercular agents in the setting of continuous venovenous haemofiltration (CVVH). We describe TDM results of numerous antitubercular agents in a critically ill patient during CVVH and haemodialysis. CASE SUMMARY A 49-year-old man was initiated on treatment for disseminated Mycobacterium tuberculosis. During hospital admission, the patient developed critical illness and required renal replacement therapy. TDM results and pharmacokinetic calculations showed adequate serum concentrations of rifampin, ethambutol and amikacin during CVVH and of rifampin, pyrazinamide, ethambutol and levofloxacin during intermittent haemodialysis. WHAT IS NEW AND CONCLUSION The presence of critical illness and renal replacement therapy can induce pharmacokinetic changes that may warrant vigilant TDM to ensure optimal therapy. To our knowledge, this is the first report to describe TDM for several antitubercular agents during CVVH in a critically patient with disseminated M. tuberculosis.
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Affiliation(s)
- J H Sin
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - R H Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - R M Hurtado
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - A R Letourneau
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - R G Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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Osei E, Der J, Owusu R, Kofie P, Axame WK. The burden of HIV on Tuberculosis patients in the Volta region of Ghana from 2012 to 2015: implication for Tuberculosis control. BMC Infect Dis 2017; 17:504. [PMID: 28724359 PMCID: PMC5517831 DOI: 10.1186/s12879-017-2598-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/10/2017] [Indexed: 11/12/2022] Open
Abstract
Background The impact of HIV on TB, and the implications for TB control, has been acknowledged as a public health challenge. It is imperative therefore to assess the burden of HIV on TB patients as an indicator for monitoring the control efforts of the two diseases in this part of the world. This study aimed at determining the burden of HIV infection in TB patients. Methods We conducted a retrospective review of TB registers in five districts of the Volta Region of Ghana. Prevalence of TB/HIV co-infection was determined. Bivariate and multivariate logistic regression were used to identify the predictors of HIV infection among TB patients and statistical significance was set at p-value <0.05. Results Of the 1772 TB patients, 1633 (92.2%) were tested for HIV. The overall prevalence of TB/HIV co-infection was (18.2%; 95% CI: 16.4–20.1). The prevalence was significantly higher among females (24.1%; 95%CI: 20.8–27.7), compared to males (15.1%; 95% CI: 13.1–17.4) (p < 0.001) and among children <15 years of age (27.0%; 95% CI: 18.2–38.1), compared to the elderly ≥70 years (3.5%; 95% CI: 1.6–7.4) (p < 0.001). Treatment success rate was higher among patients with only TB (90%; 95% CI: 88.1–91.5) than among TB/HIV co-infected patients (77.0%; 95% CI: 71.7–81.7) (p < 0.001). Independent predictors of HIV infection were found to be: being female (AOR: 1.79; 95% CI: 1.38–2.13; p < 0.001); smear negative pulmonary TB (AOR: 1.84; 95% CI: 1.37–2.47; p < 0.001); and patients registered in Hohoe, Kadjebi, and Kpando districts with adjusted odds ratios of 1.69 (95% CI: 1.13–2.54; p = 0.011), 2.29 (95% CI: 1.46–3.57; p < 0.001), and 2.15 (95% CI: 1.44–3.21; p < 0.001) respectively. Patients ≥70 years of age and those registered in Keta Municipal were less likely to be HIV positive with odds ratios of 0.09 (95% CI: 0.04–0.26; p < 0.001) and 0.62 (95% CI: 0.38–0.99; p = 0.047) respectively. Conclusion TB/HIV co-infection rate in five study districts of the Volta region is quite high, occurs more frequently in female patients than males; among smear negative pulmonary TB patients, and children <15 years of age. Findings also demonstrate that HIV co-infection affects TB treatment outcomes adversely. Strengthening the TB/HIV collaborative efforts is required in order to reduce the burden of co-infection in patients.
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Affiliation(s)
- Eric Osei
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana.
| | - Joyce Der
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Richard Owusu
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Philip Kofie
- Department of Family and Community Health, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Wisdom Kudzo Axame
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
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Cojutti P, Giangreco M, Isola M, Pea F. Limited sampling strategies for determining the area under the plasma concentration–time curve for isoniazid might be a valuable approach for optimizing treatment in adult patients with tuberculosis. Int J Antimicrob Agents 2017; 50:23-28. [DOI: 10.1016/j.ijantimicag.2017.01.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/21/2016] [Accepted: 01/22/2017] [Indexed: 11/27/2022]
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13
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Ebers A, Stroup S, Mpagama S, Kisonga R, Lekule I, Liu J, Heysell S. Determination of plasma concentrations of levofloxacin by high performance liquid chromatography for use at a multidrug-resistant tuberculosis hospital in Tanzania. PLoS One 2017; 12:e0170663. [PMID: 28141813 PMCID: PMC5283651 DOI: 10.1371/journal.pone.0170663] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 01/09/2017] [Indexed: 11/18/2022] Open
Abstract
Therapeutic drug monitoring may improve multidrug-resistant tuberculosis (MDR-TB) treatment outcomes. Levofloxacin demonstrates significant individual pharmacokinetic variability. Thus, we sought to develop and validate a high-performance liquid chromatography (HPLC) method with ultraviolet (UV) detection for levofloxacin in patients on MDR-TB treatment. The HPLC-UV method is based on a solid phase extraction (SPE) and a direct injection into the HPLC system. The limit of quantification was 0.25 μg/mL, and the assay was linear over the concentration range of 0.25—15 μg/mL (y = 0.5668x—0.0603, R2 = 0.9992) for the determination of levofloxacin in plasma. The HPLC-UV methodology achieved excellent accuracy and reproducibility along a clinically meaningful range. The intra-assay RSD% of low, medium, and high quality control samples (QC) were 1.93, 2.44, and 1.90, respectively, while the inter-assay RSD% were 3.74, 5.65, and 3.30, respectively. The mean recovery was 96.84%. This method was then utilized to measure levofloxacin concentrations from patients’ plasma samples from a retrospective cohort of consecutive enrolled subjects treated for MDR-TB at the national TB hospital in Tanzania during 5/3/2013–8/31/2015. Plasma was collected at 2 hours after levofloxacin administration, the time of estimated peak concentration (eCmax) treatment. Forty-one MDR-TB patients had plasma available and 39 had traceable programmatic outcomes. Only 13 (32%) patients had any plasma concentration that reached the lower range of the expected literature derived Cmax with the median eCmax being 5.86 (3.33–9.08 μg/ml). Using Classification and Regression Tree analysis, an eCmax ≥7.55 μg/mL was identified as the threshold which best predicted cure. Analyzing this CART derived threshold on treatment outcome, the time to sputum culture conversion was 38.3 ± 22.7 days vs. 47.8 ± 26.5 days (p = 0.27) and a greater proportion were cured, in 10 out of 15 (66.7%) vs. 6 out of 18 (33.3%) (p = 0.06) respectively. Furthermore, one patient with an eCmax/minimum inhibitory concentration (MIC) of only 1.13 acquired extensively drug resistant (XDR)-TB while undergoing treatment. The individual variability of levofloxacin concentrations in MDR-TB patients from Tanzania supports further study of the application of onsite therapeutic drug monitoring and MIC testing.
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Affiliation(s)
- Andrew Ebers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
| | - Suzanne Stroup
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
| | - Stellah Mpagama
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Riziki Kisonga
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Isaack Lekule
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
| | - Scott Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, United States of America
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Egelund EF, Dupree L, Huesgen E, Peloquin CA. The pharmacological challenges of treating tuberculosis and HIV coinfections. Expert Rev Clin Pharmacol 2016; 10:213-223. [PMID: 27828731 DOI: 10.1080/17512433.2017.1259066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is the most prevalent opportunistic infection among HIV patients, and the leading cause of death among HIV patients worldwide. Simultaneous treatment of both diseases is recommended by current guidelines, but can be challenging due to the potential for drug-drug interactions, overlapping toxicities, difficulty adhering to medications, and an increased risk for immune reconstitution inflammatory syndrome (IRIS). Clinical manifestations of TB can also vary between HIV-infected patients and uninfected patients, which can increase the risk for delayed diagnosis. Areas covered: Topics covered in this review include the following: the inter-related pathophysiology of HIV and TB; clinical manifestations and diagnosis; drug-drug interactions, particularly the rifamycins with the antiretrovirals; IRIS presentation and treatment, as well as a discussion on overlapping toxicity between the two disease states. Expert commentary: The complexity of managing these two disease states simultaneously requires a multidisciplinary approach to care and dedicated resources. If properly funded, TB/HIV co-infection will continue to decline over the coming years.
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Affiliation(s)
- Eric F Egelund
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory
| | - Lori Dupree
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Emily Huesgen
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Charles A Peloquin
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory.,c Emerging Pathogens Institute , University of Florida , Gainesville , FL , USA
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Prahl JB, Lundqvist M, Bahl JMC, Johansen IS, Andersen ÅB, Frimodt-Møller N, Cohen AS. Simultaneous quantification of isoniazid, rifampicin, ethambutol and pyrazinamide by liquid chromatography/tandem mass spectrometry. APMIS 2016; 124:1004-1015. [PMID: 27546025 DOI: 10.1111/apm.12590] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/08/2016] [Indexed: 11/30/2022]
Abstract
A remediable cause of poor treatment response in drug-susceptible tuberculosis (TB) patients may be low plasma levels of one or more of the first-line anti-TB drugs. The aim of this work was to develop an accurate and precise LC-MS/MS method for simultaneous quantification of all four first-line anti-TB drugs in plasma suitable for therapeutic drug monitoring (TDM). To adjust for degradation and losses during sample preparation, isotopically labeled compounds were used as internal standards. Plasma samples spiked with internal standards were extracted using protein precipitation with methanol and acetonitrile. Simultaneous separation of all four drugs was accomplished with a Chromolith Reversed-Phase column and mobile phases consisting of water, methanol, ammonium acetate and formic acid with subsequent mass spectrometric quantification. The linear range of the calibration curve for isoniazid was 0.5-10 mg/L, for rifampicin 0.75-30 mg/L, for ethambutol 0.25-10 mg/L and for pyrazinamide 4-80 mg/L. The lower limit of quantification was 0.5 mg/L, 0.75 mg/L, 0.25 mg/L and 4.0 mg/L, respectively. Precision estimated by the coefficient of variation was <15% for all four drugs. The LC-MS/MS method can readily be used for simultaneous quantification of first-line anti-TB drugs in plasma and is well suited for TDM.
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Affiliation(s)
- Julie B Prahl
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.
| | - Marika Lundqvist
- Department of Congenital Diseases, Statens Serum Institut, Copenhagen, Denmark
| | - Justyna M C Bahl
- Department of Autoimmunology and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
| | - Isik S Johansen
- Department of Infectious Diseases, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Åse B Andersen
- Department of Infectious Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen Ø, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen Ø, Denmark
| | - Arieh S Cohen
- Department of Congenital Diseases, Statens Serum Institut, Copenhagen, Denmark
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Pecego AC, Amancio RT, Ribeiro C, Mesquita EC, Medeiros DM, Cerbino J, Grinsztejn B, Bozza FA, Japiassu AM. Six-month survival of critically ill patients with HIV-related disease and tuberculosis: a retrospective study. BMC Infect Dis 2016; 16:270. [PMID: 27286652 PMCID: PMC4902956 DOI: 10.1186/s12879-016-1644-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 06/08/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tuberculosis is one of the leading causes of death from infectious diseases worldwide, mainly after the human immunodeficiency virus (HIV) epidemics. Patient with HIV-related illness are more likely to present with severe TB due to immunosuppression. Very few studies have explored HIV/TB co-infection in critically ill patients. The goal of this study was to analyze factors associated with long-term mortality in critically ill patient with HIV-related disease coinfected with TB. METHODS We conducted a retrospective study in an infectious disease reference center in Brazil that included all patient with HIV-related illness admitted to the ICU with laboratory-confirmed tuberculosis from March 2007 until June 2012. Clinical and laboratory variables were analyzed based on six-month survival. RESULTS Forty-four patients with HIV-related illness with a confirmed diagnosis of tuberculosis were analyzed. The six-month mortality was 52 % (23 patients). The main causes of admission were respiratory failure (41 %), severe sepsis/septic shock (32 %) and coma/torpor (14 %). The median time between HIV diagnosis and ICU admission was 5 (1-60) months, and 41 % of patients received their HIV infection diagnosis ≤ 30 days before admission. The median CD4 count was 72 (IQR: 23-136) cells/mm(3). The clinical presentation was pulmonary tuberculosis in 22 patients (50 %) and disseminated TB in 20 patients (45.5 %). No aspect of TB diagnosis or treatment was different between survivors and nonsurvivors. Neurological dysfunction was more prevalent among nonsurvivors (43 % vs. 14 %, p = 0.04). The nadir CD4 cell count lower than 50 cells/mm(3) was independently associated with Six-month mortality (hazard ratio 4.58 [1.64-12.74], p < 0.01), while HIV diagnosis less than three months after positive serology was protective (hazard ratio 0.27, CI 95 % [0.10-0.72], p = 0.01). CONCLUSION The Six-month mortality of HIV critically ill patients with TB coinfection is high and strongly associated with the nadir CD4 cell count less than 50 cels/mm(3).
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Affiliation(s)
- Ana Carla Pecego
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Rodrigo T Amancio
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Camila Ribeiro
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Emersom C Mesquita
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Denise M Medeiros
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - José Cerbino
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Beatriz Grinsztejn
- STD/AIDS Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Fernando A Bozza
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil.,Instituto D'Or de Pesquisa e Ensino, Rua Diniz Cordeiro, n° 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil
| | - Andre M Japiassu
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil.
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Karo B, Krause G, Hollo V, van der Werf MJ, Castell S, Hamouda O, Haas W. Impact of HIV infection on treatment outcome of tuberculosis in Europe. AIDS 2016; 30:1089-98. [PMID: 26752278 DOI: 10.1097/qad.0000000000001016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The effect of HIV on tuberculosis (TB) treatment outcomes has not been well established. We aimed to assess the impact of HIV infection on TB treatment outcomes by using data from notifiable disease surveillance in Europe. METHODS We analyzed the treatment outcomes of TB cases reported from nine European countries during 2010-2012. We investigate the effect of HIV on TB treatment outcomes using a multilevel and a multinomial logistic model, and considering the interaction between HIV and multidrug-resistant (MDR) TB. RESULTS A total of 61,138 TB cases including 5.5% HIV-positive were eligible for our analysis. In the multilevel model adjusted for age and an interaction with MDR TB, HIV was significantly associated with lower treatment success in all MDR strata [non-MDR TB: odds ratio (OR) 0.24 CI (confidence interval) 0.20-0.29; unknown MDR TB status: OR 0.26 CI 0.23-0.30; MDR TB: OR 0.57 CI 0.35-0.91]. In the multinomial regression model, HIV-positive cases had significantly higher relative risk ratio (RRR) for death (non-MDR TB: RRR 4.30 CI 2.31-7.99; unknown MDR TB status: 5.55 CI 3.10-9.92; MDR TB: 3.59 CI 1.56-8.28) and being 'still on treatment' (non-MDR TB: RRR 7.27 CI 3.00-17.6; unknown MDR TB status: 5.36 CI 2.44-11.8; MDR TB: 3.76 CI 2.48-5.71). We did not find any significant association between HIV and TB treatment failure (non-MDR TB: RRR 0.50 CI 0.15-1.67; unknown MDR TB status: 1.51 CI 0.86-2.64; MDR TB: 0.51 CI 0.13-1.87). CONCLUSION This large study confirms that HIV is a strong risk factor for an adverse TB treatment outcome, which is mainly manifested by an increased risk of death and still being on TB treatment.
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Lortholary O, Roussillon C, Boucherie C, Padoin C, Chaix ML, Breton G, Rami A, Veziris N, Patey O, Caumes E, May T, Molina JM, Robert J, Tod M, Fagard C, Chêne G. Tenofovir DF/emtricitabine and efavirenz combination therapy for HIV infection in patients treated for tuberculosis: the ANRS 129 BKVIR trial. J Antimicrob Chemother 2015; 71:783-93. [PMID: 26679250 DOI: 10.1093/jac/dkv384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/15/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND HIV-infected patients with TB need simplified, effective and well-tolerated antiretroviral regimens. METHODS The French ANRS 129 BKVIR open trial evaluated the once-daily tenofovir DF/emtricitabine and efavirenz combination, started within 12 weeks after TB treatment initiation, in antiretroviral-naive HIV-1-infected patients. Success was defined as an HIV-1 RNA <50 copies/mL and TB cure at 48 weeks. RESULTS TB was confirmed microbiologically (90%) or histologically (10%) in 69 patients (71% male; median age 43 years; 54% born in Africa). The median time between TB treatment initiation and antiretroviral therapy was 8 weeks (range 1-22 weeks). At baseline, median HIV-1 RNA was 5.4 log10 copies/mL and median CD4 cell count 74 cells/mm(3). In the ITT analysis, combined success at week 48 was achieved in 57/69 patients (83%, 95% CI 74-92). Twelve patients did not achieve virological success, and TB was not cured in one of them. Among the 47 patients who fully adhered to the strategy, the success rate was 96% (95% CI 90-100) and was not affected by low rifampicin and isoniazid serum concentrations. Forty-nine serious adverse events were reported in 31 patients (45%), and 11 led to antiretroviral drug interruption. All adverse events resolved. The immune reconstitution inflammatory syndrome occurred in 23 patients (33%, 95% CI 22-44), and was associated with a low baseline BMI (P = 0.03) and a low haemoglobin level (P = 0.02). CONCLUSION These results support the use of tenofovir DF/emtricitabine and efavirenz combination therapy for HIV infection in patients with TB.
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Affiliation(s)
- Olivier Lortholary
- Université Paris Descartes, APHP, Hôpital Necker Enfants Malades, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Paris, France
| | - Caroline Roussillon
- Université Bordeaux, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France
| | - Céline Boucherie
- Université Bordeaux, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France
| | - Christophe Padoin
- Hôpital Avicenne, Laboratoire de Toxicologie et de Suivi Thérapeutique, Bobigny, France
| | - Marie-Laure Chaix
- Université Paris Descartes EA 3620, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, CHU Necker-Enfants Malades, Paris, France
| | - Guillaume Breton
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Médecine Interne, Paris, France
| | - Agathe Rami
- AP-HP, Hôpital Lariboisière, Service de Médecine Interne, Paris, France
| | - Nicolas Veziris
- Sorbonne Universités, UPMC Univ Paris 06, CR7, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology), F-75013, Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Bactériologie-Hygiène, F-75013, Paris, France
| | - Olivier Patey
- Hôpital Villeneuve St-Georges, Service des Maladies Infectieuses et Tropicales, Villeneuve S-Georges, France
| | - Eric Caumes
- AP-HP, Hôpital Pitié-Salpêtrière, Service des Maladies Infectieuses et Tropicales, Paris, France
| | - Thierry May
- Hôpital Brabois, Service des Maladies Infectieuses, Nancy, France
| | - Jean-Michel Molina
- Université Paris Diderot Paris 7, Hôpital St-Louis and INSERM U941, Paris, France
| | - Jérome Robert
- Sorbonne Universités, UPMC Univ Paris 06, CR7, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology), F-75013, Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Bactériologie-Hygiène, F-75013, Paris, France
| | - Michel Tod
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Catherine Fagard
- Université Bordeaux, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France
| | - Geneviève Chêne
- Université Bordeaux, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France CHU de Bordeaux, Pôle de santé publique, Service d'information médicale, F-33000 Bordeaux, France
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Serum Levels of Antituberculosis Drugs and Their Effect on Tuberculosis Treatment Outcome. Antimicrob Agents Chemother 2015; 60:92-8. [PMID: 26459901 DOI: 10.1128/aac.00693-15] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 10/04/2015] [Indexed: 11/20/2022] Open
Abstract
Therapeutic drug monitoring in tuberculosis remains controversial. We evaluated the relationship between antituberculosis drug levels in blood and clinical outcome. Serum concentrations of first-line antituberculosis drugs were measured in tuberculosis patients between March 2006 and April 2013. Venous blood was drawn 2 h after drug ingestion and was analyzed using high-performance liquid chromatography-tandem mass spectrometry. We retrospectively reviewed the data and determined the association of serum drug levels with clinical outcome. Among 413 patients, the prevalences of low serum concentrations of isoniazid (INH), rifampin (RMP), ethambutol (EMB), and pyrazinamide (PZA) were 59.9%, 27.8%, 12.8%, and 8.7%, respectively. The low INH group had a greater percentage of patients with a history of tuberculosis treatment (19.2% versus 11.0%; P = 0.026) and was more likely to present with drug-resistant strains (17.6% versus 8.8%; P = 0.049) than the normal INH group; however, low levels of INH, RMP, EMB, and PZA were not related to treatment outcome. Low INH level had a tendency to be associated with 2-month culture positivity, but it was not statistically significant (P = 0.072) in multivariate analysis. Seventeen (4.1%) patients experienced a recurrence. However, the recurrence rate was not statistically different between the low and normal INH groups. Low serum INH may play a role in recurrence and in acquired drug resistance. However, the serum level of INH was not directly related to either treatment response or recurrence rate. The role and usefulness of therapeutic drug monitoring should be evaluated in further prospective studies.
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Wilby KJ, Ensom MHH, Marra F. Review of evidence for measuring drug concentrations of first-line antitubercular agents in adults. Clin Pharmacokinet 2015; 53:873-90. [PMID: 25172553 DOI: 10.1007/s40262-014-0170-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Measurement of drug concentrations and performing therapeutic drug monitoring (TDM) are widely used to optimize efficacy and safety of many commonly used drugs today. Although TDM of first-line antitubercular drugs is used during the treatment of tuberculosis, the extent of any benefit achieved is currently unknown. This review summarizes the available literature describing TDM of first-line treatment agents in patients with tuberculosis and describes clinical associations with achievement of target drug concentrations, including data from special populations. A literature review was conducted for articles describing drug concentration and TDM outcomes for first-line tuberculosis agents in adults. A total of 40 studies were included in the review. Studies were a mixture of controlled trials, observational studies, cross-sectional studies, and case reports. The majority of the studies showed standard dosing does not consistently achieve target concentrations for the first-line antitubercular drugs; however, the clinical implications of this finding are still unclear. Presence of HIV and diabetes mellitus appeared to indicate achievement of lower than target concentrations and this warrants further study in prospective studies. Current published data neither prove nor disprove the utility of TDM for general tuberculosis populations but evidence does not currently support routine measurement of drug concentrations.
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Affiliation(s)
- Kyle John Wilby
- College of Pharmacy, Qatar University, PO Box 2713, Doha, Qatar,
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Newman M, Foisy MM, Ahmed RA. The Use of Therapeutic Drug Monitoring in Complex Antituberculous and Antiretroviral Drug Dosing in HIV/Tuberculosis-Coinfected Patients. J Int Assoc Provid AIDS Care 2014; 14:295-9. [PMID: 25425639 DOI: 10.1177/2325957414557269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED We report 2 cases coinfected with HIV and tuberculosis (HIV/TB), requiring drug dose adjustments guided by therapeutic drug monitoring (TDM) and/or serum drug concentrations. CASE 1 Over the course of the 9-months of TB treatment, drugs that required increased doses due to low concentrations included efavirenz (800 mg), rifampin (900 mg), and isoniazid (450 mg). Higher drug doses were well tolerated until the end of treatment. CASE 2 Over the 12-month course of TB therapy, drugs that required increased doses due to incomplete and/or delayed absorption were rifampin (1500 mg), moxifloxacin (800 mg), and ethambutol (1600 mg). Higher drug doses were well tolerated until the end of treatment. Due to delayed/incomplete drug absorption and weight gain during therapy, higher antituberculous doses may be required in patients coinfected with HIV/TB. A daily dose of efavirenz 800 mg was well tolerated in both patients (weight over 70 kg). Managing patients coinfected with HIV/TB is complex, and, therefore, TDM of drug concentrations can help guide clinical decision making.
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Affiliation(s)
- Michael Newman
- BScPharm Student, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alberta, Canada
| | - Michelle M Foisy
- Northern Alberta Program, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Rabia A Ahmed
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Alsultan A, Peloquin CA. Therapeutic Drug Monitoring in the Treatment of Tuberculosis: An Update. Drugs 2014; 74:839-54. [DOI: 10.1007/s40265-014-0222-8] [Citation(s) in RCA: 280] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pharmacokinetics of rifampin and isoniazid in tuberculosis-HIV-coinfected patients receiving nevirapine- or efavirenz-based antiretroviral treatment. Antimicrob Agents Chemother 2014; 58:3182-90. [PMID: 24663014 DOI: 10.1128/aac.02379-13] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This is a substudy of the Agence Nationale de Recherches sur le Sida et les Hépatites Virales (ANRS) Comparison of Nevirapine and Efavirenz for the Treatment of HIV-TB Co-infected Patients (ANRS 12146-CARINEMO) trial, which assessed the pharmacokinetics of rifampin or isoniazid with or without the coadministration of nonnucleoside reverse transcriptase inhibitor-based HIV antiretroviral therapy in HIV-tuberculosis-coinfected patients in Mozambique. Thirty-eight patients on antituberculosis therapy based on rifampin and isoniazid participated in the substudy (57.9% males; median age, 33 years; median weight, 51.9 kg; median CD4(+) T cell count, 104 cells/μl; median HIV-1 RNA load, 5.5 log copies/ml). The daily doses of rifampin and isoniazid were 10 and 5 mg/kg of body weight, respectively. Twenty-one patients received 200 mg of nevirapine twice a day (b.i.d.), and 17 patients received 600 mg of efavirenz once a day (q.d.) in combination with lamivudine and stavudine from day 1 until the end of the study. Blood samples were collected at regular time-dosing intervals after morning administration of a fixed-dose combination of rifampin and isoniazid. When rifampin was administered alone, the median maximum concentration of drug in serum (Cmax) and the area under the concentration-time curve (AUC) at steady state were 6.59 mg/liter (range, 2.70 to 14.07 mg/liter) and 27.69 mg · h/liter (range, 11.41 to 109.75 mg · h/liter), respectively. Concentrations remained unchanged when rifampin was coadministered with nevirapine or efavirenz. When isoniazid was administered alone, the median isoniazid Cmax and AUC at steady state were 5.08 mg/liter (range, 1.26 to 11.51 mg/liter) and 20.92 mg · h/liter (range, 7.73 to 56.95 mg · h/liter), respectively. Concentrations remained unchanged when isoniazid was coadministered with nevirapine; however, a 29% decrease in the isoniazid AUC was observed when isoniazid was combined with efavirenz. The pharmacokinetic parameters of rifampin and isoniazid when coadministered with nevirapine or efavirenz were not altered to a clinically significant extent in these severely immunosuppressed HIV-infected patients. Patients experienced favorable clinical outcomes. (This study has been registered at ClinicalTrials.gov under registration no. NCT00495326.).
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Plasma drug activity in patients on treatment for multidrug-resistant tuberculosis. Antimicrob Agents Chemother 2013; 58:782-8. [PMID: 24247125 DOI: 10.1128/aac.01549-13] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Little is known about plasma drug concentrations relative to quantitative susceptibility in patients with multidrug-resistant tuberculosis (MDR-TB). We previously described a TB drug activity (TDA) assay that determines the ratio of the time to detection of plasma-cocultured Mycobacterium tuberculosis versus control growth in a Bactec MGIT system. Here, we assess the activity of individual drugs in a typical MDR-TB regimen using the TDA assay. We also examined the relationship of the TDA to the drug concentration at 2 h (C2) and the MICs among adults on a MDR-TB regimen in Tanzania. These parameters were also compared to the treatment outcome of sputum culture conversion. Individually, moxifloxacin yielded superior TDA results versus ofloxacin, and only moxifloxacin and amikacin yielded TDAs equivalent to a -2-log killing. In the 25 patients enrolled on a regimen of kanamycin, levofloxacin, ethionamide, pyrazinamide, and cycloserine, the C2 values were found to be below the expected range for levofloxacin in 13 (52%) and kanamycin in 10 (40%). Three subjects with the lowest TDA result (<1.5, a finding indicative of poor killing) had significantly lower kanamycin C2/MIC ratios than subjects with a TDA of ≥1.5 (9.8 ± 8.7 versus 27.0 ± 19.1; P = 0.04). The mean TDAs were 2.52 ± 0.76 in subjects converting to negative in ≤2 months and 1.88 ± 0.57 in subjects converting to negative in >2 months (P = 0.08). In Tanzania, MDR-TB drug concentrations were frequently low, and a wide concentration/MIC range was observed that affected plasma drug activity ex vivo. An opportunity exists for pharmacokinetic optimization in current MDR-TB regimens, which may improve treatment response.
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Development and validation of a hydrophilic interaction liquid chromatography–tandem mass spectrometry method for the simultaneous determination of five first-line antituberculosis drugs in plasma. Anal Bioanal Chem 2013; 405:6323-35. [DOI: 10.1007/s00216-013-7049-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 05/02/2013] [Accepted: 05/06/2013] [Indexed: 10/26/2022]
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Isoniazid, rifampin, and pyrazinamide plasma concentrations in relation to treatment response in Indonesian pulmonary tuberculosis patients. Antimicrob Agents Chemother 2013; 57:3614-9. [PMID: 23689725 DOI: 10.1128/aac.02468-12] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Numerous studies have reported low concentrations of antituberculosis drugs in tuberculosis (TB) patients, but few studies have examined whether low drug concentrations affect TB treatment response. We examined steady-state plasma concentrations of isoniazid, rifampin, and pyrazinamide at 2 h after the administration of drugs (C(2 h)) among 181 patients with pulmonary tuberculosis in Indonesia and related these to bacteriological response during treatment. C(2 h) values below reference values for either isoniazid, rifampin, or pyrazinamide were found in 91% of patients; 60% had at least two low C(2 h) concentrations. The isoniazid C2 h was noticeably lower in fast versus slow acetylators (0.9 mg/liter versus 2.2 mg/liter, P < 0.001). At the end of treatment, 82% of the patients were cured, whereas 30 patients (17%) had dropped out during the study, and 2 patients (1%) failed treatment. No association was found between C(2 h) concentrations and sputum culture results at 8 weeks of treatment. Post hoc analysis showed that patients with low pyrazinamide C2 h (P = 0.01) and patients with large extensive lung lesions (P = 0.01) were at risk of at least one positive culture at week 4, 8, or 24/32. Antituberculosis drug concentrations were often low, but treatment response was nevertheless good. No association was found between drug concentrations and 8 weeks culture conversion, but low pyrazinamide drug concentrations may be associated with a less favorable bacteriological response. The use of higher doses of pyrazinamide may warrant further investigation.
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Ahmed R, Cooper R, Foisy M, Der E, Kunimoto D. Factors Associated with Reduced Antituberculous Serum Drug Concentrations in Patients with HIV-TB Coinfection. ACTA ACUST UNITED AC 2012; 11:273-6. [DOI: 10.1177/1545109712454454] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe correlates of reduced antituberculous serum drug concentrations (SDCs) in HIV-infected patients receiving treatment for active tuberculosis (TB). Cross-sectional analysis of individuals diagnosed with HIV and active TB in Northern Alberta, Canada, was performed. Of the 30 HIV-TB cases, 27 underwent measurement of SDCs. Rates of low SDCs were 9 of 26 (34%) for isoniazid (INH) and 16 of 25 (64%) for rifamycins. Increased weight and elevated body mass index (BMI) correlated with low SDCs for rifampin ( P < .05) and increased weight also correlated with reduced SDCs for INH ( P < .05). This suggests that conventional antituberculous dosing may be too low and consideration should be given to increase the maximum initial weight-based doses in HIV-infected patients.
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Affiliation(s)
- Rabia Ahmed
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ryan Cooper
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Foisy
- Faculty of Pharmacy and Pharmaceutical Services, University of Alberta, Edmonton, Alberta, Canada
| | - Evelina Der
- Central TB Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Dennis Kunimoto
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is used to optimize dosing that maximizes therapeutic benefit while minimizing toxicity. In the treatment of active tuberculosis (TB), TDM is not routine, yet low levels of anti-TB drugs can be associated with poorer treatment outcomes. METHODS In a retrospective case control study, patients with active TB in whom TDM was performed were considered cases and compared with controls who did not undergo TDM, and matched according to year of diagnosis and the results of direct smear microscopy. Medical records were reviewed to abstract demographic, clinical, radiographic and microbiological data including time until smear and culture conversion. RESULTS In total, 20 patients were identified in whom TDM was performed, of whom 17 (87%) had at least one low drug concentration. Overall, 27 of 45 (60%) initial drug concentrations were low and resulted in an increased drug dosage. Low drug levels were found in 13 of 15 (87%) isoniazid, four of five (80%) rifabutin and eight of 12 (67%) rifampin measurements, but in only two of 13 (15%) pyrazinamide measurements. Within cases only, the 17 patients with low serum drug levels were significantly more likely to have comorbid illnesses, be smear positive, have lower serum albumin levels and had nonsignificantly longer time to culture conversion, compared with the three cases in whom all drug levels were within therapeutic ranges. CONCLUSIONS TB drug levels were frequently below clinically acceptable levels in patients with active TB, particularly in those with HIV infection or other comorbidities. TDM is potentially useful for the treatment of active TB, but is currently underused.
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Pho MT, Swaminathan S, Kumarasamy N, Losina E, Ponnuraja C, Uhler LM, Scott CA, Mayer KH, Freedberg KA, Walensky RP. The cost-effectiveness of tuberculosis preventive therapy for HIV-infected individuals in southern India: a trial-based analysis. PLoS One 2012; 7:e36001. [PMID: 22558301 PMCID: PMC3340407 DOI: 10.1371/journal.pone.0036001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 03/27/2012] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Regimens for isoniazid-based preventive therapy (IPT) for tuberculosis (TB) in HIV-infected individuals have not been widely adopted given concerns regarding efficacy, adherence and drug resistance. Further, the cost-effectiveness of IPT has not been studied in India. METHODS We used an HIV/TB model to project TB incidence, life expectancy, cost and incremental cost-effectiveness of six months of isoniazid plus ethambutol (6EH), thirty-six months of isoniazid (36H) and no IPT for HIV-infected patients in India. Model input parameters included a median CD4 count of 324 cells/mm(3), and a rate ratio of developing TB of 0.35 for 6EH and 0.22 for 36H at three years as compared to no IPT. Results of 6EH and 36H were also compared to six months of isoniazid (6H), three months of isoniazid plus rifampin (3RH) and three months of isoniazid plus rifapentine (3RPTH). RESULTS Projected TB incidence decreased in the 6EH and 36H regimens by 51% and 62% respectively at three-year follow-up compared to no IPT. Without IPT, projected life expectancy was 136.1 months at a lifetime per person cost of $5,630. 6EH increased life expectancy by 0.8 months at an additional per person cost of $100 (incremental cost-effectiveness ratio (ICER) of $1,490/year of life saved (YLS)). 36H further increased life expectancy by 0.2 months with an additional per person cost of $55 (ICER of $3,120/YLS). The projected clinical impact of 6EH was comparable to 6H and 3RH; however when compared to these other options, 6EH was no longer cost-effective given the high cost of ethambutol. Results were sensitive to baseline CD4 count and adherence. CONCLUSIONS Three, six and thirty-six-month regimens of isoniazid-based therapy are effective in preventing TB. Three months of isoniazid plus rifampin and six-months of isoniazid are similarly cost-effective in India, and should be considered part of HIV care.
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Affiliation(s)
- Mai T. Pho
- Section of Hospital Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, United States of America
| | | | | | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston Massachusetts, United States of America
| | - C. Ponnuraja
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Kenneth H. Mayer
- Miriam Hospital, Brown University, Providence, Rhode Island, United States of America
| | - Kenneth A. Freedberg
- Division of General Medicine
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston Massachusetts, United States of America
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Rochelle P. Walensky
- Division of General Medicine
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts, United States of America
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Abstract
Antibiotics are most commonly prescribed drugs in clinical practice. Therapeutic drug monitoring of these medications is typically associated with a select group of antibiotics such as aminoglycosides and vancomycin. Outside this group, other antibiotics such as chloramphenicol and antituberculosis agents may also require monitoring. Due to their wide therapeutic index, other classes of antibiotics such as penicillins, cephalosporin, sulfonamides, quinolones, and macrolides do not generally require routine therapeutic drug monitoring. Determination of serum or plasma concentration of these drugs, however, may be beneficial in those patients with compromised renal function. As can be expected, immunoassays for routine monitoring of aminoglycosides and vancomycin have been developed and are widely commercially available. Tests for other antibiotics, due to their infrequent use and low clinical application, are generally limited to in-house developed methods.
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Magis-Escurra C, van den Boogaard J, Ijdema D, Boeree M, Aarnoutse R. Therapeutic drug monitoring in the treatment of tuberculosis patients. Pulm Pharmacol Ther 2011; 25:83-6. [PMID: 22179055 DOI: 10.1016/j.pupt.2011.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 11/11/2011] [Accepted: 12/03/2011] [Indexed: 11/16/2022]
Abstract
At the University Centre for Chronic Diseases Dekkerswald, a tertiary tuberculosis (TB) referral hospital in The Netherlands, therapeutic drug monitoring (TDM) is used in patients in case of relapse TB, when there is delayed response to TB treatment, and when abnormal TB drug concentrations are suspected for other reasons. In this article, a case series is presented to illustrate the value of individualized TB drug dosing in four patients with low TB drug concentrations. Increased doses of the TB drugs, especially of rifampicin, resulted in adequate peak plasma concentrations and improved clinical response to treatment in these patients, while no adverse events occurred.
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Affiliation(s)
- Cecile Magis-Escurra
- Radboud University Nijmegen Medical Centre, University Centre for Chronic Diseases Dekkerswald, Nijmeegsebaan 31, 6561 KE Groesbeek, The Netherlands.
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Plasma drug activity assay for treatment optimization in tuberculosis patients. Antimicrob Agents Chemother 2011; 55:5819-25. [PMID: 21968363 DOI: 10.1128/aac.05561-11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Low antituberculosis (TB) drug levels are common, but their clinical significance remains unclear, and methods of measurement are resource intensive. Subjects initiating treatment for sputum smear-positive pulmonary TB were enrolled from Kibong'oto National TB Hospital, Tanzania, and levels of isoniazid, rifampin, ethambutol, and pyrazinamide were measured at the time of typical peak plasma concentration (C(2 h)). To evaluate the significance of the effect of observed drug levels on Mycobacterium tuberculosis growth, a plasma TB drug activity (TDA) assay was developed using the Bactec MGIT system. Time to detection of plasma-cocultured M. tuberculosis versus time to detection of control growth was defined as a TDA ratio. TDA assays were later performed using the subject's own M. tuberculosis isolate and C(2 h) plasma from the Tanzanian cohort and compared to drug levels and clinical outcomes. Sixteen subjects with a mean age of 37.8 years ± 10.7 were enrolled. Fourteen (88%) had C(2 h) rifampin levels and 11 (69%) had isoniazid levels below 90% of the lower limit of the expected range. Plasma spiked with various concentrations of antituberculosis medications found TDA assay results to be unaffected by ethambutol or pyrazinamide. Yet with a range of isoniazid and rifampin concentrations, TDA exhibited a statistically significant correlation with drug level and drug MIC, and a TDA of ~1.0 indicated the presence of multidrug-resistant TB. In Tanzania, low (≤ 2.0) TDA was significantly associated with both lower isoniazid and rifampin C(2 h) levels, and very low (≤ 1.5) TDA corresponded to a trend toward lack of cure. Study of TDA compared to additional clinical outcomes and as a therapeutic management tool is warranted.
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Heysell SK, Moore JL, Keller SJ, Houpt ER. Therapeutic drug monitoring for slow response to tuberculosis treatment in a state control program, Virginia, USA. Emerg Infect Dis 2011; 16:1546-53. [PMID: 20875279 PMCID: PMC3294393 DOI: 10.3201/eid1610.100374] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
TOC summary: Diabetes was associated with increased risk for slow response and low rifampin levels. Therapeutic drug monitoring may be useful in tuberculosis management, but programmatic implementation is understudied. We performed a retrospective cohort study to determine prevalence of lower than expected levels of isoniazid, rifampin, ethambutol, and pyrazinamide measured at time of estimated peak serum concentration. Patients were tested for serum concentration at 2 hours after medication administration. When patients were tested, 22 had concentrations lower than expected range for rifampin, 23 of 39 patients had low levels of isoniazid, and 8 of 26 patients had low levels of ethambutol; all 20 patients tested for pyrazinamide were within expected range. Over 26 months, 42 patients met criteria for slow response. Diabetes was associated with slow response (p<0.001), and persons with diabetes were more likely than persons without diabetes to have low rifampin levels (p = 0.03). Dosage adjustment of rifampin was more likely to elevate serum concentration to the target range than adjustment of isoniazid given in daily doses (p = 0.01).
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Affiliation(s)
- Scott K Heysell
- Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia 22908, USA.
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Dartois V, Barry CE. Clinical pharmacology and lesion penetrating properties of second- and third-line antituberculous agents used in the management of multidrug-resistant (MDR) and extensively-drug resistant (XDR) tuberculosis. CURRENT CLINICAL PHARMACOLOGY 2010; 5:96-114. [PMID: 20156156 PMCID: PMC6344931 DOI: 10.2174/157488410791110797] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Accepted: 12/17/2009] [Indexed: 11/22/2022]
Abstract
Failure of first-line chemotherapy to cure tuberculosis (TB) patients occurs, in part, because of the development of resistance to isoniazid (INH) and rifampicin (RIF) the two most sterilizing agents in the four-drug regimen used to treat primary infections. Strains resistant to both INH and RIF are termed multidrug-resistant (MDR). Treatment options for MDR patients involve a complex array of twenty different drugs only two classes of which are considered to be highly effective (fluoroquinolones and aminoglycosides). Resistance to these two classes results in strains known as extensively drug-resistant (XDR) and these types of infections are becoming increasingly common. Many of the remaining agents have poorly defined pharmacology but nonetheless are widely used in the treatment of this disease. Several of these agents are known to have highly variable exposures in healthy volunteers and little is known in the patients in which they must be used. Therapeutic drug monitoring (TDM) is infrequently used in the management of MDR or XDR disease yet the clinical pharmacokinetic studies that have been done suggest this might have a large impact on disease outcome. We review what is known about the pharmacologic properties of each of the major classes of second- and third-line antituberculosis agents and suggest where judicious use of TDM would have the maximum possible impact. We summarize the state of knowledge of drug-drug interactions (DDI) in these classes of agents and those that are currently in clinical trials. Finally we consider what little is known about the ability of TB drugs to reach their ultimate site of action--the interior of a granuloma by penetrating the diseased lung area. Careful consideration of the pharmacology of these agents is essential if we are to avoid further fueling the growing epidemic of highly drug-resistant TB and critical in the development of new antituberculosis drugs.
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Affiliation(s)
- Véronique Dartois
- The Novartis Institute for Tropical Diseases, Biopolis, Singapore, Singapore.
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