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Comment www.thelancet.com Vol 385 May 2, 2015 1703 Tuberculosis is a major health priority, with 9 million cases and 1·5 million deaths in 2013, of which 360 000 deaths were in people with HIV and 210 000 deaths were in people with multidrug-resistant (MDR) tuberculosis. 1–3 In several countries of the former Soviet Union, one in three new cases is caused by MDR tuberculosis. In response, WHO have proposed and scaled up various innovative global public health interventions over the past two decades, from directly observed treatment, short-course (DOTS) and the Stop TB Strategy, to the recently approved End TB Strategy. 1 These strategies and interventions support the vision of a tuberculosis-free world with no death, disease, or suffering caused by tuberculosis. 4–6 Rapid diagnosis and effective treatment of infectious cases are the pillars of the programmatic approach to tuberculosis control, although a more aggressive approach based on diagnosis and treatment of latently infected individuals has been proposed in the context of tuberculosis elimination. A vaccine that is better than BCG will be also needed. However, for the past 40 years, no new drug since rifampicin has been developed to fight tuberculosis, although substantial progress has been achieved in diagnostics (eg, the development of Xpert MTB/RIF). 7 Nowadays, whether a strain of Mycobacterium tuberculosis is resistant to rifampicin can be established in less than 2 h; this rapid detection of rifampicin resistance is regarded as a reasonable proxy of MDR tuberculosis where prevalence is high. 1 To understand how difficult these drug-resistant cases are for physicians to treat, the definition of extensively drug-resistant (XDR) tuberculosis should be considered; these strains are MDR (ie, resistant at least to isoniazid and rifampicin) and have acquired additional resistance to fluoroquinolones and injectable second-line drugs. In the largest cohort of patients with MDR tuberculosis reported (n=9153), 2 the proportion of cases treated successfully was 62%, with treatment failure or relapse occurring for 7% of patients, death in 9%, and defaulting (lost to follow-up) in 17%. In the subgroup of patients with XDR tuberculosis, treatment outcomes were even worse: treatment was successful for 40% of patients, but treatment failure or relapse occurred for 22%, 15% died, and 16% defaulted. 3,8,9 In addition to being very long (20 months or more) and very toxic, treatment of drug-resistant tuberculosis is also very expensive: in Germany, the cost of treating a patient with XDR tuberculosis exceeds €168 000 for drugs alone. 10 As a result of a multistakeholder initiative, to begin to address these issues, two new antituberculosis drugs have been approved by the US Food and Drug Administration, European Medicines Agency, or both—bedaquiline and delamanid. 11,12 In The Lancet, Rodney Dawson and colleagues 13 investigate what regimens can be designed with new antituberculosis drugs. Their phase 2b trial at eight sites in South Africa and Tanzania compared the bactericidal activity of 8 week regimens of moxifloxacin, pretomanid (previously known as PA-824; 100 mg or 200 mg, dependent on treatment group), and pyrazinamide (MPa100Z or MPa200Z regimen, as defined by pretomanid dose) with the existing standard antituberculosis regimen for drug-susceptible tuberculosis—isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE)—for the treatment of patients with sputum smear-positive, drug-susceptible, or MDR tuberculosis. 60 patients were randomly assigned to the MPa100Z group, 62 to the MPa200Z group, and 59 to the HRZE group; 26 patients with MDR tuberculosis were also given the MPa200Z regimen and treated as a separate analysis group (DRMPa200Z). By a Bayesian approach, Dawson and colleagues 13 assessed the mean daily rate of reduction in M tuberculosis colony forming units (CFUs) per mL, as a marker of bactericidal activity. Bactericidal activity was significantly increased in patients with drug-susceptible tuberculosis compared with the WHO-recommended regimen (HRZE) after 8 weeks of treatment. For patients with drug-susceptible tuberculosis, the mean change in daily log 10 CFU count was 0·155 (credibility interval 0·133–0·178) for MPa200Z, as compared with 0·112 (0·093–0·131) for HRZE. Change in bactericidal activity was 0·133 (0·109–0·155) for MPa100Z, and, for patients with MDR tuberculosis given MPa200Z, 0·117 (0·070–0·174). The safety profile and protective effect towards development of resistance was similar to that detected in the control group. 59 (29%) of 207 patients had hyperuricaemia (17 [28%] of 60 patients in the MPa100Z group, 17 [27%] of 62 patients in the MPa200Z group, 17 [29%] of 59 patients in the HRZE group, and eight [31%] of 26 patients in the DRMPa200Z group); 37 (18%) had nausea (14 [23%] in the MPa100Z group, eight [13%] in New effective antituberculosis regimens Published Online March 18, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)62303-5 See Articles page 1738 A Dowsett, Public Health England/Science Photo Library
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Transcript of 1-s2.0-S0140673614623035-main
Comment
www.thelancet.com Vol 385 May 2, 2015 1703
Tuberculosis is a major health priority, with 9 million cases and 1·5 million deaths in 2013, of which 360 000 deaths were in people with HIV and 210 000 deaths were in people with multidrug-resistant (MDR) tuberculosis.1–3 In several countries of the former Soviet Union, one in three new cases is caused by MDR tuberculosis. In response, WHO have proposed and scaled up various innovative global public health interventions over the past two decades, from directly observed treatment, short-course (DOTS) and the Stop TB Strategy, to the recently approved End TB Strategy.1 These strategies and interventions support the vision of a tuberculosis-free world with no death, disease, or suff ering caused by tuberculosis.4–6
Rapid diagnosis and eff ective treatment of infectious cases are the pillars of the programmatic approach to tuberculosis control, although a more aggressive approach based on diagnosis and treatment of latently infected individuals has been proposed in the context of tuberculosis elimination. A vaccine that is better than BCG will be also needed. However, for the past 40 years, no new drug since rifampicin has been developed to fi ght tuberculosis, although substantial progress has been achieved in diagnostics (eg, the development of Xpert MTB/RIF).7 Nowadays, whether a strain of Mycobacterium tuberculosis is resistant to rifampicin can be established in less than 2 h; this rapid detection of rifampicin resistance is regarded as a reasonable proxy of MDR tuberculosis where prevalence is high.1
To understand how diffi cult these drug-resistant cases are for physicians to treat, the defi nition of extensively drug-resistant (XDR) tuberculosis should be considered; these strains are MDR (ie, resistant at least to isoniazid and rifampicin) and have acquired additional resistance to fl uoroquinolones and injectable second-line drugs. In the largest cohort of patients with MDR tuberculosis reported (n=9153),2 the proportion of cases treated successfully was 62%, with treatment failure or relapse occurring for 7% of patients, death in 9%, and defaulting (lost to follow-up) in 17%. In the subgroup of patients with XDR tuberculosis, treatment outcomes were even worse: treatment was successful for 40% of patients, but treatment failure or relapse occurred for 22%, 15% died, and 16% defaulted.3,8,9 In addition to being very long (20 months or more) and very toxic, treatment of drug-resistant tuberculosis is also very expensive: in Germany, the cost of treating a patient
with XDR tuberculosis exceeds €168 000 for drugs alone.10 As a result of a multistakeholder initiative, to begin to address these issues, two new antituberculosis drugs have been approved by the US Food and Drug Administration, European Medicines Agency, or both—bedaquiline and delamanid.11,12
In The Lancet, Rodney Dawson and colleagues13 investigate what regimens can be designed with new antituberculosis drugs. Their phase 2b trial at eight sites in South Africa and Tanzania compared the bactericidal activity of 8 week regimens of moxifl oxacin, pretomanid (previously known as PA-824; 100 mg or 200 mg, dependent on treatment group), and pyrazinamide (MPa100Z or MPa200Z regimen, as defi ned by pretomanid dose) with the existing standard antituberculosis regimen for drug-susceptible tuberculosis—isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE)—for the treatment of patients with sputum smear-positive, drug-susceptible, or MDR tuberculosis. 60 patients were randomly assigned to the MPa100Z group, 62 to the MPa200Z group, and 59 to the HRZE group; 26 patients with MDR tuberculosis were also given the MPa200Z regimen and treated as a separate analysis group (DRMPa200Z).
By a Bayesian approach, Dawson and colleagues13 assessed the mean daily rate of reduction in M tuberculosis colony forming units (CFUs) per mL, as a marker of bactericidal activity. Bactericidal activity was signifi cantly increased in patients with drug-susceptible tuberculosis compared with the WHO-recommended regimen (HRZE) after 8 weeks of treatment. For patients with drug-susceptible tuberculosis, the mean change in daily log10CFU count was 0·155 (credibility interval 0·133–0·178) for MPa200Z, as compared with 0·112 (0·093–0·131) for HRZE. Change in bactericidal activity was 0·133 (0·109–0·155) for MPa100Z, and, for patients with MDR tuberculosis given MPa200Z, 0·117 (0·070–0·174).
The safety profi le and protective eff ect towards develop ment of resistance was similar to that detected in the control group. 59 (29%) of 207 patients had hyperuricaemia (17 [28%] of 60 patients in the MPa100Z group, 17 [27%] of 62 patients in the MPa200Z group, 17 [29%] of 59 patients in the HRZE group, and eight [31%] of 26 patients in the DRMPa200Z group); 37 (18%) had nausea (14 [23%] in the MPa100Z group, eight [13%] in
New eff ective antituberculosis regimens
Published OnlineMarch 18, 2015http://dx.doi.org/10.1016/S0140-6736(14)62303-5
See Articles page 1738
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Comment
1704 www.thelancet.com Vol 385 May 2, 2015
In The Lancet, Gunnar Buyse and colleagues1 report the results of DELOS, a double-masked, randomised, placebo-controlled, multicentre, phase 3 trial investigating the effi cacy of idebenone on respiratory outcomes in patients with Duchenne muscular dystrophy. The authors report for the fi rst time the possible effi cacy of a non-steroidal drug in a cohort of patients with Duchenne muscular dystrophy, most of whom were non-ambulant. The results are promising
because of the favourable safety profi le of idebenone, but also show that challenges exist for studies in people with this disease, especially non-ambulant patients, and raise questions about the choice of outcome measures and inclusion criteria for this population.
In the past few years, several experimental therapies have been studied in p atients with Duchenne muscular dystrophy2 and this research has strongly encouraged international collaboration to identify suitable outcome
Effi cacy of idebenone in Duchenne muscular dystrophy
the MPa200Z group, seven [12%] in the HRZE group, and eight [31%] in the DRMPa200Z group); and 25 (13%) had vomiting (seven [12%] in the MPa100Z group, seven [11%] in the MPa200Z group, seven [12%] in the HRZE group, and four [15%] in the DRMPa200Z group). Importantly, no episodes of QT interval in excess of 500 ms were identifi ed.
Dawson and colleagues’ results13 are encouraging for several reasons. First, the investigators have shown the effi cacy of a rifampicin-sparing regimen, which has the potential to improve the ease and safety of treatment of patients with HIV taking protease inhibitors. Second, the 8 week period needed to achieve sputum culture conversion might benefi t the individual patient (ie, rapid recovery) and the community (ie, reduced M tuberculosis transmission). The potential exists to shorten treatment duration and thereby improve adherence. As the investigators note,13 the effi cacy of the rifampicin-sparing regimen in patients with MDR tuberculosis needs further investigation, since the study was not powered to detect an eff ect in the small subgroup of patients with MDR disease. Furthermore, the positive protective eff ect on the emergence of phenotypic drug resistance identifi ed in this study needs to be further assessed in the longer term, especially during the continuation phase of treatment.
Much work still needs to be done to improve the present approach to clinical trials of antituberculosis drugs. The surrogate markers adopted to measure effi cacy are old and need complex statistical approaches. Furthermore, the time needed to assess the pharmacological profi le of a new drug is still very long, and the diffi culty of enrolling susceptible individuals into trials is a further barrier.9 The new WHO End TB Strategy aims to support these eff orts needed for research on new antituberculosis drugs.
Giovanni Sotgiu, *Giovanni Battista MiglioriClinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy (GS); and WHO Collaborating Centre for TB and Lung Diseases, Fondazione S Maugeri, Care and Research Institute, Tradate 21049, Italy (GBM) [email protected]
We declare no competing interests.
1 WHO. Global tuberculosis report 2014. Geneva: World Health Organization, 2014.
2 Falzon D, Gandhi N, Migliori GB, et al, on behalf of the Collaborative Group for Meta-Analysis of Individual Patient Data in MDR-TB. Resistance to fl uoroquinolones and second-line injectable drugs: impact on MDR-TB outcomes. Eur Respir J 2013; 42: 156–68.
3 Migliori GB, Sotgiu G, Gandhi NR; Collaborative Group for Meta-Analysis of Individual Patient Data in MDR-TB. Drug resistance beyond extensively drug resistant tuberculosis: individual patient data meta-analysis. Eur Respir J 2013; 42: 169–79.
4 Sotgiu G, Migliori GB. Is tuberculosis elimination a reality? Lancet Infect Dis 2014; 14: 364–65.
5 Migliori GB, Sotgiu G. Measuring the eff ect of tuberculosis control: a step forward. Lancet 2014; 383: 2026–28.
6 Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review. Eur Respir J 2014; 43: 1763–75.
7 Weyer K, Mirzayev F, Migliori GB, et al. Rapid molecular TB diagnosis: evidence, policy making and global implementation of Xpert MTB/RIF. Eur Respir J 2013; 42: 252–71.
8 Raviglione M, Uplekar M, Vincent C, Pablos-Méndez A. Rebalancing the global battle against tuberculosis. Lancet Glob Health 2014; 2: e71–72.
9 Zumla AI, Schito M, Maeurer M. Advancing the portfolio of tuberculosis diagnostics, drugs, biomarkers, and vaccines. Lancet Infect Dis 2014; 14: 267–69.
10 Diel R, Rutz S, Castell S, Schaberg T. Tuberculosis: cost of illness in Germany. Eur Respir J 2012; 40: 143–51.
11 Skripconoka V, Danilovits M, Pehme L. Delamanid improves outcomes and reduces mortality in multidrug-resistant tuberculosis. Eur Respir J 2013; 41: 1393–400.
12 Diacon AH, Pym A, Grobusch MP, et al, for the TMC207-C208 Study Group. Multidrug-resistant tuberculosis and culture conversion with bedaquiline. N Engl J Med 2014; 371: 723–32.
13 Dawson R, Diacon AH, Everitt D, et al. Effi ciency and safety of the combination of moxifl oxacin, pretomanid (PA-824), and pyrazinamide during the fi rst 8 weeks of antituberculosis treatment: a phase 2b, open-label, partly randomised trial in patients with drug-susceptible or drug-resistant pulmonary tuberculosis. Lancet 2015; published online March 18. http://dx.doi.org/10.1016/S0140-6736(14)62002-X.
Published OnlineApril 21, 2015
http://dx.doi.org/10.1016/S0140-6736(15)60758-9
See Articles page 1748
