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- 1. UoG CSH-TIC Catchment Area Meeting October, 2023 Tilahun Nega (MD, UoG CSH-TB focal)
- 2. Presentation outline • Update on DR-TB treatment • Principles of drug resistant TB treatment • Nationally recommended DR-TB treatment regimens in Ethiopia • The 6-month BPaLM regimen • The 9-month all-oral regimen • Longer RR/MDR-TB treatment regimen • Triage for RR/MDR-TB regimen • Treatment monitoring & follow-up of MDR/RR-TB patients • Hr-TB treatment
- 3. Objectives • By the end of this session, participants will be able to: • Identify medicines used in DR-TB treatment • Describe principles of designing DR-TB treatment regimen • Discuss the current DR-TB treatment regimens in Ethiopia • Identify treatment recommendations in different conditions • Monitor Treatment and follow up of DR-TB patient.
- 4. Updates of DR-TB treatment • PMDT updated very frequently • Since the start of new drug regimen updated three times • The most update is April 2023 • Incorporated updates in treatment
- 5. Medicines used in DR-TB treatment
- 6. Principles of drug resistant TB treatment • Detect RR-/MDR-TB early and initiate effective treatment promptly • RR/MDR-TB diagnosis must be confirmed for rifampicin and if possible for isoniazid using rapid molecular DST techniques • Bacteriologically confirmed RR/MDRTB TB patients are recommended to have baseline screening DST for core-second lines medicines at least for fluoroquinolones. • Pulmonary RR/MDR TB patients must submit sputum specimen for SL-DST before treatment initiation with DR-TB Regimen. • The use of mWRDs such as Xpert MTB/XDR Assay is recommended as the preferred test to detect additional resistance to SLDs.
- 7. Conti… • Never add a single TB medicine for TB patients receiving likely failing regimen • Any patient – child or adult – with RR/MDR-TB be treated with the recommended MDR- TB treatment regimen, either the 6-month bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM) regimen, the 9-months all oral regimen, or longer regimens • Individualized regimen for eligible patients should be constructed at the level of clinical panel team in consultation with the national/regional clinical review committee (CRC)
- 8. Nationally Recommended DR-TB treatment regimens in Ethiopia The DR-TB Regimen options in Ethiopia are: • A. RR/MDR-TB Regimens • 1. The 6-month bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM) regimen. • 2. The 9-month all-oral Regimens (Eto or Lzd containing) • 3. Individualized Longer Regimens • B. Hr-TB Regimen: 6 (H)RZE-Lfx
- 9. Conti…
- 10. The 6-month BPaLM regimem • The 6-month bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM) regimen is the newly recommended regimen in the treatment of RR/MDR-TB patients • This regimen should be the preferred initial choice for all eligible patients diagnosed with MDR/RR-TB rather than the 9-month or longer (18-month) regimens in the treatment of MDR/RR-TB patients
- 11. Composition & duration of the 6-month BPaL/M RR/MDR-TB Regimen The BPaLM regimen includes four components: Bedaquiline, Pretomanid, Linezolid and moxifloxacin When initiating the regimen, it is important to ensure that patients have not had previous exposure to bedaquiline, linezolid, pretomanid or delamanid for more than 1-month duration When exposure is greater than 1 month, these patients may still receive these regimens if resistance to the specific medicines with such exposure has been ruled out
- 12. Conti… There are slight differences in the treatment duration of the BPaLM and BPaL regimens. A standardized treatment duration of BPaLM to 6 months (26 weeks or 180 days) is recommended during programmatic implementation For BPaL, the possibility of an extension to a total of 9 months (39 weeks) if sputum cultures are positive between months 4 and 6 is suggested
- 13. Conti.. • DST for fluoroquinolones is strongly encouraged in people with MDR/RR-TB, and although it should not delay initiation of the BPaLM, results of the test should guide the decision on whether moxifloxacin can be retained or should be dropped from the regimen • In cases of documented resistance to fluoroquinolones, BPaL without moxifloxacin would be initiated or continued
- 14. Eligibility Criteria for BPaLM
- 15. BPaL regimen • The BPaL regimen can be prescribed for those who have proven fluoroquinolone resistance • In cases of possible fluoroquinolone resistance, it is best to use the BPaLM regimen until DST for fluoroquinolones is available, to decide whether or not moxifloxacin should be continued
- 16. Duration of treatment for BPaLM • Patients with susceptibility to fluoroquinolones can be started on the BPaLM regimen for 6 months (26 weeks) • In the case of resistance to fluoroquinolones, identified after treatment initiation, moxifloxacin may be discontinued and the regimen can be continued as BPaL • When the regimen is BPaL from the start or is changed to BPaL, it can be extended to a total of 9 months (39 weeks) (continuing from the start of the therapy with BPaLM/BPaL) • This extension of the BPaL regimen can occur in cases where there is a lack of culture conversion or clinical response (based on the clinical judgement of the treating physician) between months 4 and 6 • Treatment interruption up to 1 month can be added to the overall treatment duration if there is a need to make up the missed doses
- 17. Conti.. • Temporary cessation of the full regimen is allowed for suspected drug- related toxicity • Reintroduction of the full regimen could be considered after a cessation of no more than 14 days of consecutive treatment interruption or up to a cumulative 4 weeks of nonconsecutive treatment interruption • Missed doses need to be made up and added to the treatment duration • Individuals who switch from BPaLM to BPaL should consider their treatment start date the same as the date BPaLM was initiated, because the patient remained on treatment with three effective drugs during the entire treatment period
- 18. Management of treatment interruptions in BPaL/M Regimens
- 19. Treatment monitoring in BPaLM Regimen • Monthly sputum spear microscopy and culture • Clinical assessment for regimen effectiveness & safety • Post treatment follow-up to assess relapse/side effects
- 20. Monitoring schedules for BPaLM Regimen
- 21. Conti…
- 22. The updated definition of treatment failure for BPaL/M regimen Adverse drug reactions Poor bacteriological/clinical response to treatment Acquired drug resistant to drugs in BPaLM/BPaL
- 23. The 9-month all-oral regimen
- 24. Composition and duration of the 9-months regimen
- 25. Management of Bedaquline interruption in all oral 9 months regimen
- 26. Conti… • If, for any reason, a patient is unable to tolerate pyrazinamide or ethambutol within the 9month regimen, then one (but only one) of these drugs may be dropped during the continuation phase without necessitating a switch to a longer regimen • If two or more of these drugs are not tolerated within the 9-month regimen, the treatment will have to switch to a longer regimen • If any of the other drugs within the 9-month regimen (bedaquiline, levofloxacin/moxifloxacin, linezolid/ ethionamide or clofazimine) are stopped early because of toxicity or intolerance then the patient will also have to switch to a new regimen • Patients switching to a new regimen due to toxicity or intolerance need to be reported as “treatment failed
- 27. Treatment Response Monitoring Chart for patients on 9-month MDR/RR-TB Regimen
- 28. Longer MDR/RR-TB treatment regimen
- 29. Summary of Grouping of medicines used in longer RR/MDR- TB Regimens
- 31. Diagnosis and Management of Rifampicin susceptible and isoniazid resistant TB (Hr-TB) • DIAGNOSIS OF INH MONO-RESISTANT TUBERCULOSIS (Hr-TB) • Hr-TB is more prevalent than RR/MDR-TB. Globally in 2019, an estimated 13.1% (95% CI: 9.9– 16.9%) of new cases and 17.4% (95% CI: 0.5–54%) of previously treated cases had isoniazid resistance • An estimated 1.4 million (range, 1.0–1.9 million) incident cases of isoniazid- resistant TB in 2019, of which 1.1 million (range, 0.6–1.5 million) were susceptible to rifampicin. In other words, 11% (range, 6.5–15%) of all incident cases of TB had isoniazid-resistant and rifampicin-susceptible TB
- 32. Conti… Ethiopian DRS 2019 Report has shown that: Any INH resistance was detected in 6.16% of TB cases - the highest DR-TB rate. The prevalence of Hr-TB was found to be 2.34% (95% CI 1.6 %-3.3%) and 4.24% (95% CI 1.4% -9.6%) among new and previously treated TB cases
- 33. Hr-TB Case finding and Diagnosis • Hr-TB Case finding shall focus on identifying the high-risk groups for Hr-TB among presumptive cases as well as among diagnosed TB cases • The Hr-TB high risk groups include the following: I. Close/Household contacts of a known Hr-TB case II. TB patients (both new and previously treated) with poor/inadequate response to standard DS-TB regimen: remain sputum smear positive at 2nd month or later with FLDs, poor radiological or clinical response to treatment, etc. III.All previously treated TB cases: Relapses, treatment after failure, treatment after loss to follow up cases, IV.All TB patients coming from areas/settings with high Hr-TB rates.
- 34. Current Hr-TB Diagnostic Methods in Ethiopia Xpert MTB/XDR Assay (preferred) FL-LPA Phenotypic DST
- 35. Testing Recommendations for Hr- TB Detection among new TB cases/presumptive TB cases. All new TB cases/presumptive TB cases with a contact of known Hr-TB case All New TB cases with follow up sputum AFB positive at the end of 2nd month or later while on DS-TB treatment. 2nd Month Sputum AFB positive result 5th month Sputum AFB positive result 6th month Sputum AFB positive result Testing recommendations for Hr-TB detection among previously treated TB cases All previously treated PTB cases as a baseline evaluation All previously treated PTB cases with a contact of known Hr-TB case All previously TB cases with follow up sputum AFB positive at the end of 2nd month or later while on DS-TB treatment. 2nd Month Sputum AFB positive result 5th month Sputum AFB positive result 6th month Sputum AFB positive result
- 36. Indications for use of Xpert MTB/XDR assay in Ethiopia
- 37. Treatment of Hr-T • The recommended Hr-TB regimen in Ethiopia:
- 38. Decision table for initiation of Hr-TB Regimen in Ethiopia
- 39. Adjuvant Therapies in DR TB • Corticosteroid • Pyridoxine supplementation • Surgical intervention
- 40. Treatment Monitoring and Follow Up in MDR/RR-TB The monitoring should follow standard clinical assessment: A) Clinical history: Resolution or worsening of symptoms of TB (cough sputum production, hemoptysis, chest pain, respiratory distress, fever and weight loss). Asses for adherence (missed PO doses, missed injections, reasons) Symptoms for drug adverse events Systematic assessment for co-morbid illness Reproductive age women: Assess for Pregnancy, assess FP need.
- 41. Conti… • b) Physical examination: To be done as per the monitoring schedule c) Laboratory monitoring: Laboratory monitoring and other investigations are important for documenting response and identifying complications earlier Laboratory tests should be done based on schedules and when necessary based on clinical indication
- 44. Thank you!
- 45. Let’s offer Chance for Veracity to Triumph!.
Editor's Notes
- In cases of possible fluoroquinolone resistance (e.g. a history of >4 weeks of fluoroquinolone use or close contact with a person infected with a fluoroquinolone-resistant strain), it is best to initiate a BPaLM regimen until DST for fluoroquinolones is available, to decide whether moxifloxacin should be continued. If the result of fluoroquinolone DST is never determined or not done, the BPaLM regimen should be used throughout. This is often done even if fluoroquinolone resistance is suspected, because the toxicity of adding moxifloxacin is low and some patients with past use of a fluoroquinolone or contact cases may still be infected with susceptible strains.
- (e.g. a history of >4 weeks of fluoroquinolone use or close contact with a person infected with a fluoroquinolone resistant strain) Where DST is pending, BPaLM can be commenced, subsequently dropping moxifloxacin from the regimen once fluoroquinolone resistance is confirmed. The BPaL regimen uses the same doses for pretomanid, bedaquiline and linezolid as the BPaLM regimen. If fluoroquinolone resistance is acquired while an individual is on the BPaLM regimen, in the absence of evidence of acquired resistance to other drugs, moxifloxacin can be omitted and BPaL should be continued, because there is no added benefit to continuing a noneffective drug that may have toxicities. If resistance to bedaquiline, linezolid or pretomanid is confirmed or suspected, the treatment is considered to have failed and individuals should be referred to the longer individualized regimen
- In general, action should be taken in the following manner for the common toxicities associated with linezolid: o for optic neuritis diagnosed at any grade, permanent discontinuation of linezolid is indicated; o for peripheral neuropathy Grade 2, reduce the dose of linezolid to 300 mg per day with a possible drug holiday for 1–2 weeks before dose reduction; o for peripheral neuropathy Grade 3 or 4, in most cases permanent suspension of linezolid will be needed; in some cases, after a 1–2-week drug holiday and reversion to Grade 2, the linezolid can be restarted and tolerated, provided it does not revert back to a Grade 3 or 4 (caution is warranted with this approach because patients can be left with a severe painful and disabling permanent peripheral neuropathy); and o myelosuppression (even of Grade 3 or 4) is often reversible with a short 1-to-2week drug holiday followed by reducing the dose of linezolid to 300 mg per day; severe anaemia may need to be treated with transfusions or erythropoietin.
- *26 or 39 weeks of prescribed doses should be completed within an overall period of 7 (BPaLM) or 10 (BPaL) months respectively
- It is advisable to send sputum specimens for culture and DST more frequently (at least every 2 weeks) during the month 4-6 treatment period to improve results availability for early management decisions.
- The 9-month all-oral MDR/RR-TB regimen should be implemented as a standardized package. It is not advisable to change the composition of the regimen or the duration of either the initial or continuation phase, with a few exceptions, as follows: Bedaquiline is usually given for 6 months but may be extended to 9 months if the initial phase of the regimen is extended from 4 to 6 months because of positive sputum smears at month 4 of treatment Linezolid is only given for 2 months (instead of 4–6 months of ethionamide). If occasional doses of linezolid are missed during that time, the missed doses can be added on to the end of the 2-month period if the patient is tolerating the drug well. Prothionamide may be used instead of ethionamide. Moxifloxacin may be used instead of levofloxacin.
- The total length of a long treatment regimen is 18 to 20 months. In MDR/RR-TB patients on longer regimens, total treatment duration of 18–20 months is suggested for most patients; the duration may be modified according to the patient’s response to therapy. In MDR/RR-TB patients on longer regimens, treatment duration of 15–17 months after culture conversion is suggested for most patients; the duration may be modified according to the patient’s response to therapy
- 1.All new TB cases with poor response to standard DS-TB treatment (Clinical, Radiological or bacteriologic) 2. Hr-TB screening of among new bacteriologically confirmed cases after ruling out RR-TB - considered with expanded introduction of the Xpert MTB/XDR Assay 3.All previously TB cases with poor response to standard DS-TB treatment (Clinical, Radiological or bacteriologic)
- All medicines in this regimen are to be used daily for 6 months. When fixed-dose combination formulations are used, isoniazid is included but is not obligatory for the regimen. If Hr-TB Regimen: 6(H)REZ-Lfx . levofloxacin cannot be used because there is fluoroquinolone resistance or intolerance or other contraindications to the use of fluoroquinolone, then 6(H)REZ may be prescribed daily for 6 months.