From the Guidelines
The treatment of multidrug-resistant tuberculosis (MDR-TB) in patients with HIV should prioritize a comprehensive approach, starting with prompt initiation of antiretroviral therapy (ART) and a 6-month treatment regimen composed of bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) for MDR/RR-TB patients, as recommended by the latest guidelines 1. This approach is based on the most recent and highest quality study, which suggests that the BPaLM regimen is a valid option for MDR/RR-TB patients, including those with extensive pulmonary TB and extrapulmonary TB, except for TB involving the central nervous system, miliary TB, and osteoarticular TB. The key components of the treatment regimen include:
- Bedaquiline (400mg daily for 2 weeks, then 200mg three times weekly)
- Pretomanid
- Linezolid (600mg daily, potentially reduced to 300mg if toxicity occurs)
- Moxifloxacin (400mg daily) Additional considerations include:
- Close monitoring for drug interactions and overlapping toxicities
- Pyridoxine (50-100mg daily) to prevent peripheral neuropathy
- Therapeutic drug monitoring to optimize dosing
- Treatment adherence support, nutritional supplementation, and management of immune reconstitution inflammatory syndrome (IRIS)
- Monthly sputum cultures to monitor treatment response, with treatment success defined as culture conversion maintained until completion of therapy. It is essential to note that longer (18-month) treatments remain a valid option in cases where shorter regimens cannot be implemented due to intolerance, drug-drug interactions, extensively drug-resistant tuberculosis, extensive forms of extrapulmonary TB, or previous failure, as suggested by previous guidelines 1.
From the Research
Step-by-Step Treatment of MDR TB in Patients with HIV
- The treatment of multidrug-resistant tuberculosis (MDR TB) in patients with HIV requires a comprehensive approach, involving the use of multiple drugs and careful management of potential interactions between anti-TB and antiretroviral therapies 2, 3.
- The current recommended regimens for MDR TB treatment include the use of new and repurposed drugs, which have shown excellent bactericidal and sterilizing activity against Mycobacterium tuberculosis 2.
- Concurrent treatment of MDR TB and HIV has been shown to improve survival and cure rates in patients with MDR TB-HIV coinfection, with studies demonstrating that patients on antiretroviral therapy (ART) have high rates of survival and treatment success 4, 5.
- The management of MDR TB in patients with HIV requires careful consideration of diagnostic testing, the impact and timing of ART on mortality, anti-MDR TB and antiretroviral drug interactions, and the potential role for short-course MDR TB therapy 5.
- Factors such as CD4 count, HIV viral load, and prior history of TB can affect treatment outcomes in patients with MDR TB-HIV coinfection, and should be carefully monitored and managed throughout treatment 4, 6.
- A multidisciplinary approach to patient care, involving public health case management and provider expertise in drug-resistant TB and HIV management, is necessary to optimize treatment outcomes in patients with MDR TB-HIV coinfection 5.