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Amorim G, Jaworski J, Cordeiro-Santos M, Kritski AL, Figueiredo MC, Turner M, Andrade BB, Velez Edwards DR, Santos AR, Rolla VC, Sterling TR, Haas DW. Pharmacogenetics of tuberculosis treatment toxicity and effectiveness in a large Brazilian cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.30.23294860. [PMID: 37693472 PMCID: PMC10491388 DOI: 10.1101/2023.08.30.23294860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Background Genetic polymorphisms have been associated with risk of anti-tuberculosis treatment toxicity. We characterized associations with adverse events and treatment failure/recurrence among adults treated for tuberculosis in Brazil. Methods Participants were followed in Regional Prospective Observational Research in Tuberculosis (RePORT)-Brazil. We included persons with culture-confirmed drug-susceptible pulmonary tuberculosis who started treatment between 2015-2019, and who were evaluable for pharmacogenetics. Treatment included 2 months of isoniazid, rifampin or rifabutin, pyrazinamide, and ethambutol, then 4 months of isoniazid and rifampin or rifabutin, with 24 month follow-up. Analyses included 43 polymorphisms in 20 genes related to anti-tuberculosis drug hepatotoxicity or pharmacokinetics. Whole exome sequencing was done in a case-control toxicity subset. Results Among 903 participants in multivariable genetic association analyses, NAT2 slow acetylator status was associated with increased risk of treatment-related grade 2 or greater adverse events, including hepatotoxicity. Treatment failure/recurrence was more likely among NAT2 rapid acetylators, but not statistically significant at the 5% level. A GSTM1 polymorphism (rs412543) was associated with increased risk of treatment-related adverse events, including hepatotoxicity. SLCO1B1 polymorphisms were associated with increased risk of treatment- related hepatoxicity and treatment failure/recurrence. Polymorphisms in NR1/2 were associated with decreased risk of adverse events and increased risk of failure/recurrence. In whole exome sequencing, hepatotoxicity was associated with a polymorphism in VTI1A , and the genes METTL17 and PRSS57 , but none achieved genome-wide significance. Conclusions In a clinical cohort representing three regions of Brazil, NAT2 acetylator status was associated with risk for treatment-related adverse events. Additional significant polymorphisms merit investigation in larger study populations.
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Moore DP, Hesseling AC, Marx FM. Prolonged-course tuberculosis treatment or secondary prevention for those at high risk of recurrence? Clin Microbiol Infect 2022; 28:631-633. [DOI: 10.1016/j.cmi.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/03/2022]
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Muliaditan M, Della Pasqua O. How long will treatment guidelines for TB continue to overlook variability in drug exposure? J Antimicrob Chemother 2020; 74:3274-3280. [PMID: 31360999 DOI: 10.1093/jac/dkz319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/23/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Despite wide clinical acceptance, the use of weight-banded dosing regimens for the treatment of TB in adults has been defined on an empirical basis. The potential impact of known covariate factors on exposure to different drugs has not been taken into account. OBJECTIVES To evaluate the effect of demographic factors on the exposure to standard of care drugs after weight-banded dosing, as currently recommended by TB treatment guidelines. In addition, we aim to identify alternative dosing regimens that ensure comparable systemic exposure across the overall patient population. METHODS Clinical trial simulations were performed to assess the differences in systemic exposure in a cohort of virtual patients. Secondary pharmacokinetic parameters were used to evaluate the adequacy of each regimen along with the percentage of patients achieving predefined thresholds. RESULTS Our results show that patients weighing less than 40 kg are underexposed relative to patients with higher body weight. The opposite trend was observed following a crude weight band-based dosing regimen with 50 kg as the cut-off point. Simulations indicate that a fixed-dose regimen based on three (<40 kg), four (40-70 kg) or five (>70 kg) tablets of 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide and 275 mg ethambutol reduces variability in exposure, increasing the overall probability of favourable long-term outcome across the population. CONCLUSIONS These findings suggest the need to revisit current guidelines for the dose of standard of care drugs for TB treatment in adults. The proposed fixed-dose regimen should be considered in future clinical trials.
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Affiliation(s)
- Morris Muliaditan
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK.,Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline, Uxbridge, UK
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Jia CG, Gao JG, Liu FS, Li Z, Dong ZL, Yao LM, Wang LB, Yao XW. Efficacy, safety and prognosis of treating neurological deficits caused by spinal tuberculosis within 4 weeks' standard anti-tuberculosis treatment: A single medical center's experience. Exp Ther Med 2020; 19:519-526. [PMID: 31885698 PMCID: PMC6913340 DOI: 10.3892/etm.2019.8253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/29/2019] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to retrospectively analyze the safety and efficacy of the early surgical management of thoracic tuberculosis (TB) in patients with neurological deficits. The medical data of patients with thoracic TB exhibiting neurological deficit in the Chest Hospital of Hebei Province were retrospectively reviewed. A total of 234 cases, including 123 males and 115 females, were recruited in the present study. Their pre- and postoperative neurological deficit and pain levels were assessed using the 2002 American spinal injury association (ASIA) impairment scale and visual analog scale, respectively. Patients were divided into two groups according to whether their preoperative standardized anti-TB treatment time was ≥4 weeks or <4 weeks. There was no difference in blood loss and operation time between the two groups. The erythrocyte sedimentation rate was higher in patients receiving standard anti-TB <4 weeks prior to and 1 month following surgery compared with the ≥4 weeks group, but the difference was not significant 6 months following surgery. ASIA scale scores all increased significantly 1 month following surgery in the <4 weeks group compared with the ≥4 weeks group (P=0.001) though there was no difference between the scores prior to surgery. ASIA scale scores improved to 4.4±0.5 and 4.5±0.4 in patients with anti-TB treatment times of ≥4 weeks and <4 weeks, respectively, 24 months following surgery (P=0.0895). The present study demonstrated that for patients with thoracic TB exhibiting neurological deficit, early surgical management following <4 weeks' standard anti-TB treatment is recommended. It may relieve spinal cord compression and also benefit the early recovery of neurological function in these patients.
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Affiliation(s)
- Chen-Guang Jia
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Jian-Guo Gao
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Feng-Sheng Liu
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Zhuo Li
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Zhao-Liang Dong
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Li-Ming Yao
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Lian-Bo Wang
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
| | - Xiao-Wei Yao
- Department of Orthopedics, The Chest Hospital of Hebei Province, Shijiazhuang, Hebei 050041, P.R. China
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Romanowski K, Balshaw RF, Benedetti A, Campbell JR, Menzies D, Ahmad Khan F, Johnston JC. Predicting tuberculosis relapse in patients treated with the standard 6-month regimen: an individual patient data meta-analysis. Thorax 2018; 74:291-297. [PMID: 30420407 DOI: 10.1136/thoraxjnl-2017-211120] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 08/14/2018] [Accepted: 10/08/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Relapse continues to place significant burden on patients and tuberculosis (TB) programmes worldwide. We aimed to determine clinical and microbiological factors associated with relapse in patients treated with the WHO standard 6-month regimen and then evaluate the accuracy of each factor at predicting an outcome of relapse. METHODS A systematic review was performed to identify randomised controlled trials reporting treatment outcomes on patients receiving the standard regimen. Authors were contacted and invited to share patient-level data (IPD). A one-step IPD meta-analysis, using random intercept logistic regression models and receiver operating characteristic curves, was performed to evaluate the predictive performance of variables of interest. RESULTS Individual patient data were obtained from 3 of the 12 identified studies. Of the 1189 patients with confirmed pulmonary TB who completed therapy, 67 (5.6%) relapsed. In multipredictor analysis, the presence of baseline cavitary disease with positive smear at 2 months was associated with an increased odds of relapse (OR 2.3(95% CI 1.3 to 4.2)) and a relapse risk of 10%. When area under the curve for each multipredictor model was compared, discrimination between low-risk and higher-risk patients was modest and similar to that of the reference model which accounted for age, sex and HIV status. CONCLUSION Despite its poor predictive value, our results indicate that the combined presence of cavitary disease and 2-month positive smear status may be the best currently available marker for identifying individuals at an increased risk of relapse, particularly in resource-limited setting. Further investigation is required to assess whether this combined factor can be used to indicate different treatment requirements in clinical practice.
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Affiliation(s)
- Kamila Romanowski
- TB Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Robert F Balshaw
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Faiz Ahmad Khan
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - James C Johnston
- TB Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Naidoo K, Dookie N. Insights into Recurrent Tuberculosis: Relapse Versus Reinfection and Related Risk Factors. Tuberculosis (Edinb) 2018. [DOI: 10.5772/intechopen.73601] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kendall EA, Shrestha S, Cohen T, Nuermberger E, Dooley KE, Gonzalez-Angulo L, Churchyard GJ, Nahid P, Rich ML, Bansbach C, Forissier T, Lienhardt C, Dowdy DW. Priority-Setting for Novel Drug Regimens to Treat Tuberculosis: An Epidemiologic Model. PLoS Med 2017; 14:e1002202. [PMID: 28045934 PMCID: PMC5207633 DOI: 10.1371/journal.pmed.1002202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Novel drug regimens are needed for tuberculosis (TB) treatment. New regimens aim to improve on characteristics such as duration, efficacy, and safety profile, but no single regimen is likely to be ideal in all respects. By linking these regimen characteristics to a novel regimen's ability to reduce TB incidence and mortality, we sought to prioritize regimen characteristics from a population-level perspective. METHODS AND FINDINGS We developed a dynamic transmission model of multi-strain TB epidemics in hypothetical populations reflective of the epidemiological situations in India (primary analysis), South Africa, the Philippines, and Brazil. We modeled the introduction of various novel rifampicin-susceptible (RS) or rifampicin-resistant (RR) TB regimens that differed on six characteristics, identified in consultation with a team of global experts: (1) efficacy, (2) duration, (3) ease of adherence, (4) medical contraindications, (5) barrier to resistance, and (6) baseline prevalence of resistance to the novel regimen. We compared scale-up of these regimens to a baseline reflective of continued standard of care. For our primary analysis situated in India, our model generated baseline TB incidence and mortality of 157 (95% uncertainty range [UR]: 113-187) and 16 (95% UR: 9-23) per 100,000 per year at the time of novel regimen introduction and RR TB incidence and mortality of 6 (95% UR: 4-10) and 0.6 (95% UR: 0.3-1.1) per 100,000 per year. An optimal RS TB regimen was projected to reduce 10-y TB incidence and mortality in the India-like scenario by 12% (95% UR: 6%-20%) and 11% (95% UR: 6%-20%), respectively, compared to current-care projections. An optimal RR TB regimen reduced RR TB incidence by an estimated 32% (95% UR: 18%-46%) and RR TB mortality by 30% (95% UR: 18%-44%). Efficacy was the greatest determinant of impact; compared to a novel regimen meeting all minimal targets only, increasing RS TB treatment efficacy from 94% to 99% reduced TB mortality by 6% (95% UR: 1%-13%, half the impact of a fully optimized regimen), and increasing the efficacy against RR TB from 76% to 94% lowered RR TB mortality by 13% (95% UR: 6%-23%). Reducing treatment duration or improving ease of adherence had smaller but still substantial impact: shortening RS TB treatment duration from 6 to 2 mo lowered TB mortality by 3% (95% UR: 1%-6%), and shortening RR TB treatment from 20 to 6 mo reduced RR TB mortality by 8% (95% UR: 4%-13%), while reducing nonadherence to the corresponding regimens by 50% reduced TB and RR TB mortality by 2% (95% UR: 1%-4%) and 6% (95% UR: 3%-10%), respectively. Limitations include sparse data on key model parameters and necessary simplifications to model structure and outcomes. CONCLUSIONS In designing clinical trials of novel TB regimens, investigators should consider that even small changes in treatment efficacy may have considerable impact on TB-related incidence and mortality. Other regimen improvements may still have important benefits for resource allocation and outcomes such as patient quality of life.
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Affiliation(s)
- Emily A. Kendall
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- * E-mail:
| | - Sourya Shrestha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
| | - Ted Cohen
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Eric Nuermberger
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
| | - Kelly E. Dooley
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- Johns Hopkins University School of Medicine, Division of Clinical Pharmacology, Baltimore, Maryland, United States of America
| | | | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, San Francisco, California, United States of America
| | - Michael L. Rich
- Partners In Health, Boston, Massachusetts, United States of America
- Brigham and Women's Hospital, Division of Global Health Equity, Boston, Massachusetts, United States of America
| | - Cathy Bansbach
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Thomas Forissier
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - David W. Dowdy
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
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Genomic Epidemiology of Tuberculosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1019:79-93. [DOI: 10.1007/978-3-319-64371-7_4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Alffenaar JWC, Akkerman OW, Anthony RM, Tiberi S, Heysell S, Grobusch MP, Cobelens FG, Van Soolingen D. Individualizing management of extensively drug-resistant tuberculosis: diagnostics, treatment, and biomarkers. Expert Rev Anti Infect Ther 2016; 15:11-21. [PMID: 27762157 DOI: 10.1080/14787210.2017.1247692] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Success rates for treatment of extensively drug resistant tuberculosis (XDR-TB) are low due to limited treatment options, delayed diagnosis and inadequate health care infrastructure. Areas covered: This review analyses existing programmes of prevention, diagnosis and treatment of XDR-TB. Improved diagnostic procedures and rapid molecular tests help to select appropriate drugs and dosages. Drugs dosages can be further tailored to the specific conditions of the patient based on quantitative susceptibility testing of the M. tuberculosis isolate and use of therapeutic drug monitoring. Pharmacovigilance is important for preserving activity of the novel drugs bedaquiline and delamanid. Furthermore, biomarkers of treatment response must be developed and validated to guide therapeutic decisions. Expert commentary: Given the currently poor treatment outcomes and the association of XDR-TB with HIV in endemic regions, a more patient oriented approach regarding diagnostics, drug selection and tailoring and treatment evaluation will improve treatment outcome. The different areas of expertise should be covered by a multidisciplinary team and may involve the transition of patients from hospitalized to home or community-based treatment.
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Affiliation(s)
- Jan-Willem C Alffenaar
- a Dept of Clinical Pharmacy and Pharmacology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Onno W Akkerman
- b University of Groningen, University Medical Center Groningen, Tuberculosis Center Beatrixoord , Haren , The Netherlands.,c Department of Pulmonary Diseases and Tuberculosis , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Richard M Anthony
- d Royal Tropical Institute (KIT), KIT Biomedical Research , Amsterdam , The Netherlands
| | - Simon Tiberi
- e Division of Infection , Barts Healthcare NHS Trust , London , United Kingdom
| | - Scott Heysell
- f Division of Infectious Diseases and International Health , University of Virginia , Charlottesville , VA , USA
| | - Martin P Grobusch
- g Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center , University of Amsterdam , Amsterdam , The Netherlands
| | - Frank G Cobelens
- h Department of Global Health, Academic Medical Centre , University of Amsterdam , Amsterdam , The Netherlands.,i Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands.,j KNCV Tuberculosis Foundation , The Hague , The Netherlands
| | - Dick Van Soolingen
- k National Tuberclosis Reference Laboratory , National Institute for Public Health and the Environment (RIVM) , Bilthoven , The Netherlands.,l Radboud University Nijmegen Medical Center , Departments of Pulmonary Diseases and Medical Microbiology , Nijmegen , The Netherlands
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