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Treatment regimen for Tuberculosis (TB) disease

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Tuberculosis (TB) remains a significant public health concern worldwide. It is the second leading cause of death from infectious diseases. Effective adherence to TB treatment is essential in preventing disease transmission, ensuring cure, and preventing the development of drug resistance, relapse, and mortality (1).


TB treatment regimens vary based on medication types, dosing, frequency, regimen duration, and whether the TB infection is drug-sensitive or resistant. There are different guidelines for the treatment regimen based on the type of infection (2). 


Treatment of latent TB infection


The National Tuberculosis Controllers Association (NTCA) and the Centres for Disease Control and Prevention (CDC) recommend the following regimens for the treatment of latent TB infection:


  • 3 months of once-weekly Isoniazid + Rifapentine

  • 4 months of daily Rifampin

  • 3 months of daily Isoniazid + Rifampin

  • 6 or 9 months of Isoniazid monotherapy (less preferred)


Of the above-listed regimens it recommends preferring short-course therapy regimens over longer ones as they are more successful, safer, and less likely to cause hepatotoxicity (3).


Treatment of drug-susceptible TB disease


The treatment of drug-susceptible TB disease requires four anti-TB medications known collectively as the RIPE regimen (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol). There are 3 types of TB treatment plans of which the 6-month treatment plan is used in most patients. Each treatment plan is divided into an intensive phase followed by a continuation phase (Table 1) (2).


Table 1: 4, 6, 9 month treatment regimen for drug-susceptible TB disease(2).


Treatment of drug-resistant TB disease


The CDC advises using at least five medications in the intense phase of treatment (5–7 months duration following culture conversion), and four drugs in the maintenance phase of treatment, for the selection of an efficient multi-drug-resistant (MDR-TB) treatment regimen. After culture conversion, the total treatment course would last anywhere between 15 and 21 months. However, patients who are extensively drug-resistant (XDR) or pre-extensively drug-resistant (pre-XDR) will need treatment for a total of 15 to 24 months (4).


The following oral medications are recommended for MDR-TB treatment, listed in order of strength of recommendation (4):


  • Later-generation fluoroquinolone (levofloxacin or moxifloxacin),

  • Bedaquiline

  • Linezolid

  • Clofazimine

  • Cycloserine

  • Ethambutol (only if a total of five drugs can't be combined with other more effective medications).


Amikacin or streptomycin (where susceptibility to these medications is confirmed) or a carbapenem (always to be taken with amoxicillin-clavulanic acid) are the choices of drugs provided through injection when necessary to create an effective treatment regimen for MDR-TB (4).


When a safe and effective treatment plan cannot be offered, the CDC advises using pretomanid 200 mg daily for 26 weeks in the treatment of individuals with pulmonary XDR or treatment-intolerant (TI)/nonresponsive (NR) multidrug-resistant TB. It is exclusively approved for the treatment of pulmonary TB, and neither its use alone nor its combination with other anti-TB drugs that are not part of the BPaL regimen (5).


Challenges to treatment adherence


Research shows that many factors influence TB treatment adherence. These include the lack of knowledge about TB and treatment, difficulty accessing health services, social stigma, medication side effects, long treatment periods, and poor communication with healthcare providers. Drug side effects and long treatment duration are significant barriers to adherence (1). 


Conclusion


Tuberculosis (TB) remains a major public health concern globally, and adherence to TB treatment is crucial for successful outcomes. Various factors such as lack of knowledge, social stigma, and medication side effects affect treatment adherence. Treatment regimens vary depending on the type of TB infection, and it is essential to follow the appropriate guidelines to ensure effective and safe treatment. With proper adherence to treatment, we can prevent disease transmission, ensure a cure, and reduce the development of drug resistance, relapse, and mortality.  

About the Author


Paribha Gupta holds an MSc in Microbiology and is a passionate medical writer and researcher. She loves to travel and makes time to write articles on health and well-being.


References


  1. Gebreweld FH, et al. Factors influencing adherence to tuberculosis treatment in Asmara, Eritrea: a qualitative study. J Health Popul Nutr. 2018 Jan 5;37(1):1.

  2. CDC. Treatment for TB Disease. Available at:    https://www.cdc.gov/tb/topic/treatment/tbdisease.htm Accessed on 27th April 2023.

  3. Sterling TR, et al. Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep. 2020 Feb 14;69(1):1-11.

  4. Nahid P, et al. Treatment of Drug-Resistant Tuberculosis. An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline. Am J Respir Crit Care Med. 2019 Nov 15;200(10):e93-e142. 

  5. CDC. Provisional CDC Guidance for the Use of Pretomanid as part of a Regimen [Bedaquiline, Pretomanid, and Linezolid (BPaL)] to Treat Drug-Resistant Tuberculosis Disease. Available at:    https://www.cdc.gov/tb/topic/drtb/bpal/default.htm Accessed on 27th April 2023.  

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