What is the standard treatment for Latent Tuberculosis (LTB)?

From the Guidelines

The standard treatment for latent tuberculosis infection (LTBI) is a 3- to 4-month rifamycin-based regimen, which is preferred over longer-course isoniazid monotherapy due to its higher effectiveness, safety, and treatment completion rates. According to the 2020 guidelines for the treatment of LTBI, the three preferred rifamycin-based regimens are 3 months of once-weekly isoniazid plus rifapentine, 4 months of daily rifampin, or 3 months of daily isoniazid plus rifampin 1. These regimens have been shown to be effective in preventing progression to active tuberculosis disease, which is a major public health concern. The choice of regimen should be based on individual patient factors, such as age, potential drug interactions, and risk of liver disease. Regular monitoring for side effects, particularly liver function tests, is also crucial during treatment. Vitamin B6 (pyridoxine) 25-50 mg daily may be prescribed with isoniazid to prevent peripheral neuropathy.

Some key points to consider when treating LTBI include:

• The importance of treating LTBI to prevent progression to active tuberculosis disease, which can be difficult to treat and potentially contagious to others 1
• The need for regular monitoring for side effects, particularly liver function tests, during treatment
• The importance of choosing a regimen that is tailored to the individual patient's needs and factors, such as age and potential drug interactions
• The preference for rifamycin-based regimens over longer-course isoniazid monotherapy due to their higher effectiveness, safety, and treatment completion rates.

It is essential to note that these guidelines apply to persons with LTBI who live in the United States and are infected with M. tuberculosis that is presumed to be susceptible to isoniazid or rifampin. If evidence is available that the infecting M. tuberculosis strain is resistant to both isoniazid and rifampin, alternative treatment regimens should be considered. Local and state TB programs in the United States can provide guidance on diagnosing and treating persons with LTBI in their jurisdictions.

From the FDA Drug Label

For Treatment of Tuberculosis Isoniazid is used in conjunction with other effective anti-tuberculosis agents. There are 3 regimen options for the initial treatment of tuberculosis in children and adults: Option 1: Daily isoniazid, rifampin, and pyrazinamide for 8 weeks followed by 16 weeks of isoniazid and rifampin daily or 2 to 3 times weekly. Option 2: Daily isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol for 2 weeks followed by twice weekly administration of the same drugs for 6 weeks, subsequently twice weekly isoniazid and rifampin for 16 weeks. Option 3: Three times weekly with isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin for 6 months

The standard treatment for tuberculosis typically involves a combination of anti-tuberculosis agents, including:

• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol or streptomycin The treatment regimens include:
• Option 1: Daily treatment for 8 weeks, followed by 16 weeks of daily or twice-weekly treatment
• Option 2: Daily treatment for 2 weeks, followed by twice-weekly treatment for 6 weeks, and then twice-weekly treatment for 16 weeks
• Option 3: Three times weekly treatment for 6 months These regimens are used for the initial treatment of tuberculosis in children and adults, as stated in the drug label 2.

From the Research

Standard Treatment for Latent Tuberculosis

• The standard treatment for latent tuberculosis is nine months of isoniazid taken daily, or twice weekly under direct observation by a healthcare worker 3.
• Taking isoniazid and rifapentine once weekly for 12 weeks under direct observation is an alternative for patients >12 years old 3.
• Rifamycin-based regimens for latent TB infection (LTBI) have been successful in preventing progression to TB disease 4.

Standard Treatment for Active Tuberculosis

• First-line therapy for active tuberculosis (TB) has remained unchanged for nearly 40 years, and includes isoniazid, rifampin, pyrazinamide, and ethambutol for the initial two-month phase, followed by isoniazid and rifampin for 4 to 7 months 4.
• Directly-observed therapy (DOT) remains the standard of care for pulmonary TB 4.
• The standard treatment regimen for drug-susceptible tuberculosis includes isoniazid, rifampin, and pyrazinamide, although fluoroquinolones are being investigated as a replacement for isoniazid 5.

Treatment Duration and Efficacy

• Shortened treatment regimens that are equally effective and safe could improve treatment success, but evidence to date does not support the use of shortened ATT regimens in adults with newly diagnosed drug-sensitive pulmonary tuberculosis 6.
• Four-month ATT regimens that replace ethambutol with moxifloxacin or gatifloxacin, or isoniazid with moxifloxacin, increase relapse substantially compared to standard six-month ATT regimens 6.
• Newer studies are investigating even shorter LTBI treatment with durations of less than 2 months 4.