Increased risk of hepatotoxicity and temporary drug withdrawal during treatment of active tuberculosis in pregnant women

A protocol for a systematic review and meta-analysis of tuberculosis care around the time of pregnancy

Background

Tuberculosis is estimated to cause 1.5 million deaths annually and is most common during the reproductive years. Despite that fact, we found that tuberculosis screening, prevention or care recommendations for people around the time of pregnancy were absent from some national policy recommendations and varied in others.

Objectives

To address the apparent gaps and inconsistencies in policy, we aim to design a systematic review and meta-analysis of the original research evidence informing tuberculosis care around the time of pregnancy.

Methods

With assistance from librarians at the Biomedical library of the University of Gothenburg, Pubmed, CINAHL and Scopus databases will be searched. Search terms will aim to identify studies generating original research evidence informing care for tuberculosis around the time of pregnancy. Evidence may include: the outcome of TB and/or of pregnancy; the cost-effectiveness or acceptability of any intervention; the sensitivity and specificity of any assessment, selection, diagnostic or test criterion. The output from these literature searches will be screened by two independent reviewers to select the eligible studies for inclusion. Discrepancies will be resolved with a third reviewer. Firstly, publications that provide contextual data will be tabulated, summarising their main contributions. Secondly, studies that provide evidence directly guiding patient care will be our focus and will be considered to be key. The key studies will be subject to quality assessment, data extraction and when possible, meta-analysis.

Conclusions

This systematic review and meta-analysis aims to guide policy, practice and future research priorities concerning tuberculosis care around the time of pregnancy.

Pharmacokinetics and safety of first-line tuberculosis drugs rifampin, isoniazid, ethambutol, and pyrazinamide during pregnancy and postpartum: results from IMPAACT P1026s

Physiological changes during pregnancy may alter the pharmacokinetics (PK) of antituberculosis drugs. The International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026s was a multicenter, phase IV, observational, prospective PK and safety study of antiretroviral and antituberculosis drugs administered as part of clinical care in pregnant persons living with and without HIV. We assessed the effects of pregnancy on rifampin, isoniazid, ethambutol, and pyrazinamide PK in pregnant and postpartum (PP) persons without HIV treated for drug-susceptible tuberculosis disease. Daily antituberculosis treatment was prescribed following World Health Organization-recommended weight-band dosing guidelines. Steady-state 12-hour PK profiles of rifampin, isoniazid, ethambutol, and pyrazinamide were performed during second trimester (2T), third trimester (3T), and 2-8 of weeks PP. PK parameters were characterized using noncompartmental analysis, and comparisons were made using geometric mean ratios (GMRs) with 90% confidence intervals (CI). Twenty-seven participants were included: 11 African, 9 Asian, 3 Hispanic, and 4 mixed descent. PK data were available for 17, 21, and 14 participants in 2T, 3T, and PP, respectively. Rifampin and pyrazinamide AUC0-24 and C max in pregnancy were comparable to PP with the GMR between 0.80 and 1.25. Compared to PP, isoniazid AUC0-24 was 25% lower and C max was 23% lower in 3T. Ethambutol AUC0-24 was 39% lower in 3T but limited by a low PP sample size. In summary, isoniazid and ethambutol concentrations were lower during pregnancy compared to PP concentrations, while rifampin and pyrazinamide concentrations were similar. However, the median AUC0-24 for rifampin, isoniazid, and pyrazinamide met the therapeutic targets. The clinical impact of lower isoniazid and ethambutol exposure during pregnancy needs to be determined.

A protocol for a systematic review and meta-analysis of tuberculosis care around the time of pregnancy

Background: Tuberculosis is estimated to cause 1.5 million deaths annually and is most common during the reproductive years. Despite that fact, we found that tuberculosis screening, prevention or care recommendations for people around the time of pregnancy were absent from some national policy recommendations and varied in others. Objectives: To address the apparent gaps and inconsistencies in policy, we aim to design a systematic review and potential meta-analysis of the original research evidence informing tuberculosis care around the time of pregnancy. Methods: With assistance from librarians at the Biomedical library of the University of Gothenburg, Pubmed, CINAHL and Scopus databases will be searched. Search terms will aim to identify studies generating original research evidence informing care for tuberculosis around the time of pregnancy. Two independent reviewers will screen and select for inclusion the eligible studies. Discrepancies will be resolved with a third reviewer. We anticipate triaging the eligible publications. Firstly, publications that provide contextual data will be tabulated, summarising their main contributions. Secondly, studies that provide evidence directly guiding patient care and have recently been systematically reviewed and meta-analysed will be tabulated with the recently published conclusions of the syntheses of their data. Thirdly, studies that provide evidence directly guiding patient care, but have not been the subject of recent systematic review and meta-analysis will be our focus and will be considered to be key. The key studies will be subject to quality assessment, data extraction and when possible, meta-analysis. Conclusions: This systematic review and potential meta-analysis aims to guide policy, practice and future research priorities concerning tuberculosis care around the time of pregnancy.

Association of tuberculosis treatment with pregnancy complications: A protocol for systematic review and meta-analysis

BACKGROUND

The increasing burden of tuberculosis (TB) remains a very serious concern around the world, and account for a decreased quantity and quality of life. However, there is a limited epidemiology of the association of TB treatment with pregnancy. We aim to assess the effects of TB treatment in pregnancy complications.

METHODS

This will be a systematic review and meta-analysis of published studies on the association of TB treatment with pregnancy, retrieved from ScienceDirect, Web of Science, LILACS, Pubmed, Google scholar, Embase, Medline, ResearchGate, EBSCOhost and Cochrane library databases. The eligibility of the studies will be screened in accordance to the selection criteria by two independent reviewers. The quality and risk of bias of eligible studies will be performed by both reviewers using the Hoy tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool in accordance to the measured outcomes (Hypertension in pregnancy, Pre-eclampsia, Hypertensive disorders of pregnancy, Fetal growth restriction, Miscarriage and Recurrent spontaneous abortion). A data charting table will be used to extract background information and process the data items from each eligible study. The data will be analysed using Review Manager 5.3 (RevMan 5.3) software. Generic Inverse Variance method will be used for meta-analysis of both, individually and cluster randomized trials.

ETHICS AND DISSEMINATION

The review and meta-analysis will not require ethical approval and the findings will be published in peer-reviewed journals and presented at local and international conferences. In addition, the study findings will be made accessible to the national committee of TB to formulate TB guidelines for their respective settings.

SYSTEMATIC REVIEW REGISTRATION

International prospective Register of Systematic Reviews (PROSERO) number: CRD42021231872.

Liver injury associated with drug intake during pregnancy

Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.