Liver toxicity associated with tuberculosis chemotherapy in the REMoxTB study

Clinical Features of Anti-Tuberculosis Drug-Induced Liver Injury and Risk Factors for Severe Cases: A Retrospective Study in China

Background

Anti-tuberculosis drug-induced liver injury (ATB-DILI) is a common adverse reaction associated with tuberculosis (TB) treatment, significantly impacting treatment adherence and therapeutic outcomes. However, large-scale studies on hospitalized patients in China remain limited.

Purpose

To characterize the clinical features and liver injury patterns in hospitalized TB patients with ATB-DILI and to identify risk factors associated with severe ATB-DILI.

Methods

We retrospectively reviewed 28,753 hospitalized TB patients at Beijing Chest Hospital from 2014 to 2023. ATB-DILI was diagnosed in 567 patients (2.0%) based on serum biochemical criteria and causality assessment. Demographic, clinical, and laboratory data were analyzed to characterize liver injury types and identify risk factors for severe cases. Subgroup analyses based on liver injury patterns were performed to further evaluate the association between age and severe ATB-DILI.

Results

Overall, 567 cases with ATB-DILI (2.0%) were analyzed. Hepatocellular injury was the most common type (71.4%), followed by cholestatic (13.8%) and mixed (14.8%) injury patterns. Most patients (68.4%) were asymptomatic and diagnosed via routine biochemical monitoring; jaundice occurred in 18.2%. Patients with hepatocellular damage were significantly younger, while those with cholestatic injury were older (p < 0.001). Severe ATB-DILI occurred in 46 patients (8.1%), with advanced age (≥60 years) identified as an independent risk factor (OR = 2.45, 95% CI: 1.33-4.52, p = 0.004). Subgroup analysis showed that this association between age and severe ATB-DILI was significant in the hepatocellular injury type (unadjusted OR = 3.59, 95% CI: 1.61-8.02, p = 0.002), while no statistically significant association was observed in cholestatic or mixed types, which may reflect limited statistical power in these subgroups.

Conclusion

Routine liver function monitoring and age-specific risk assessment are essential for early identification and management of ATB-DILI in hospitalized TB patients.

Incidence, Clinical Features, Associated Factors and Outcomes of Intensive Phase Antituberculosis Drug Induced Liver Injury Among Patients With Tuberculosis at a Tertiary Care Hospital in Nepal: A Descriptive Cross-Sectional Study

Background and Aims

Tuberculosis (TB) remains a significant global health concern, especially in Nepal, where the incidence of anti-TB drug-induced liver injury (DILI) is substantial. The main aim of this study is to investigate the incidence, clinical characteristics, outcomes, and contributing factors related to intensive phase anti-TB DILI among TB patients.

Methods

This prospective cross-sectional study enrolled 78 TB patients. Patients received a weight-based fixed-dose Antitubercular therapy (ATT). Liver function tests (LFTs) were performed at baseline and periodically during treatment to monitor for anti-TB DILI. Patients with DILI received immediate ATT discontinuation, supportive care, and reintroduction of ATT upon LFT normalization. Outcomes were tracked up to 60 days post-DILI. Data were analyzed using SPSS v21. Statistical significance was set at p < 0.05.

Results

The mean age of the patients was 49.87 years (SD = 18.61), and 57.7% were male. Anti-TB DILI was observed in 15.4% of patients during the intensive treatment phase, with moderate severity in 50% of these cases. Half of the patients with DILI presented with nausea, vomiting, and anorexia. Notably, 91.7% of DILI patients showed improvement upon treatment discontinuation. The recurrence rate of anti-TB DILI after ATT re-initiation was 8.3%. Anti-TB DILI developed at a median of 11 days (range: 7-60 days) after ATT initiation, with liver enzyme normalization after discontinuation of ATT averaging 10.9 ± 6.45 days. The mortality rate among DILI patients was 8.3% (1 out of 12 patients). Hepatotoxic drugs, low BMI, and low serum albumin were identified as independent predictors of anti-TB DILI.

Conclusion

Anti-TB DILI occurred in a significant proportion of TB patients, with moderate severity being most common. Early detection and management, including treatment discontinuation, led to high recovery rates, though mortality remained notable. Low BMI, low serum albumin, and hepatotoxic drugs were key independent risk factors, emphasizing the need for careful monitoring and tailored management during ATT.

Assessing hepatotoxicity in novel and standard short regimens for rifampicin-resistant tuberculosis: Insights from the TB-TRUST and TB-TRUST-plus trials

OBJECTIVES

Efforts to shorten rifampicin-resistant tuberculosis (RR-TB) treatment have led to concerns about hepatotoxicity in shorter regimens. We evaluated hepatotoxicity in two novel regimens against the standard shorter regimen recommended by the World Health Organization (WHO).

METHODS

Participants from the TB-TRUST and TB-TRUST plus trials were assigned to the WHO shorter regimen, a levofloxacin (Lfx)-based regimen, or a bedaquiline (Bdq)-based regimen. Liver function was tested bi-weekly in the first month, then monthly until treatment ended. Eligibility required receiving at least one drug dose and undergoing at least two liver function tests.

RESULTS

Of 429 patients, hepatotoxicity was most prevalent in the WHO shorter group (26.7% of 169), compared to 4.7% in the Lfx group (172 patients), and 5.7% in the Bdq group (88 patients). The median peak alanine aminotransferase levels were 1.67 × upper limit of normal (ULN) for WHO, 0.82 × ULN for Lfx, and 0.88 × ULN for Bdq groups. The incidence of drug-induced liver injury was significantly higher in the WHO group (18.3%) than in the Lfx (3.5%) and Bdq (4.6%) groups. The time to significant alanine aminotransferase elevation was about 2.8 months, with no differences between groups.

CONCLUSIONS

Two novel regimens demonstrated lower hepatotoxicity compared to the WHO's shorter regimen. Entire course management monitoring is recommended in RR-TB treatment.

Predictive machine learning models for anticipating loss to follow-up in tuberculosis patients throughout anti-TB treatment journey

Loss to follow-up (LTFU) in tuberculosis (TB) management increases morbidity and mortality, challenging effective control strategies. This study aims to develop and evaluate machine learning models to predict loss to follow-up in TB patients, improving treatment adherence and outcomes. Retrospective data encompassing tuberculosis patients who underwent treatment or registration at the National Center for Clinical Medical Research on Infectious Diseases from January 2017 to December 2021 were compiled. Employing machine learning techniques, namely SVM, RF, XGBoost, and logistic regression, the study aimed to prognosticate LTFU. A comprehensive cohort of 24,265 tuberculosis patients underwent scrutiny, revealing a LTFU prevalence of 12.51% (n = 3036). Education level, history of hospitalization, alcohol consumption, outpatient admission, and prior tuberculosis history emerged as precursors for pre-treatment LTFU. Employment status, outpatient admission, presence of chronic hepatitis/cirrhosis, drug adverse reactions, alternative contact availability, and health insurance coverage exerted substantial influence on treatment-phase LTFU. XGBoost consistently surpassed alternative models, boasting superior discriminative ability with an average AUC of 0.921 for pre-treatment LTFU and 0.825 for in-treatment LTFU. Our study demonstrates that the XGBoost model provides superior predictive performance in identifying LTFU risk among tuberculosis patients. The identification of key risk factors highlights the importance of targeted interventions, which could lead to significant improvements in treatment adherence and patient outcomes.

Interpretable machine learning in predicting drug-induced liver injury among tuberculosis patients: model development and validation study

BACKGROUND

The objective of this research was to create and validate an interpretable prediction model for drug-induced liver injury (DILI) during tuberculosis (TB) treatment.

METHODS

A dataset of TB patients from Ningbo City was used to develop models employing the eXtreme Gradient Boosting (XGBoost), random forest (RF), and the least absolute shrinkage and selection operator (LASSO) logistic algorithms. The model's performance was evaluated through various metrics, including the area under the receiver operating characteristic curve (AUROC) and the area under the precision recall curve (AUPR) alongside the decision curve. The Shapley Additive exPlanations (SHAP) method was used to interpret the variable contributions of the superior model.

RESULTS

A total of 7,071 TB patients were identified from the regional healthcare dataset. The study cohort consisted of individuals with a median age of 47 years, 68.0% of whom were male, and 16.3% developed DILI. We utilized part of the high dimensional propensity score (HDPS) method to identify relevant variables and obtained a total of 424 variables. From these, 37 variables were selected for inclusion in a logistic model using LASSO. The dataset was then split into training and validation sets according to a 7:3 ratio. In the validation dataset, the XGBoost model displayed improved overall performance, with an AUROC of 0.89, an AUPR of 0.75, an F1 score of 0.57, and a Brier score of 0.07. Both SHAP analysis and XGBoost model highlighted the contribution of baseline liver-related ailments such as DILI, drug-induced hepatitis (DIH), and fatty liver disease (FLD). Age, alanine transaminase (ALT), and total bilirubin (Tbil) were also linked to DILI status.

CONCLUSION

XGBoost demonstrates improved predictive performance compared to RF and LASSO logistic in this study. Moreover, the introduction of the SHAP method enhances the clinical understanding and potential application of the model. For further research, external validation and more detailed feature integration are necessary.

Synergistic toxicity with copper contributes to NAT2-associated isoniazid toxicity

Anti-tuberculosis (AT) medications, including isoniazid (INH), can cause drug-induced liver injury (DILI), but the underlying mechanism remains unclear. In this study, we aimed to identify genetic factors that may increase the susceptibility of individuals to AT-DILI and to examine genetic interactions that may lead to isoniazid (INH)-induced hepatotoxicity. We performed a targeted sequencing analysis of 380 pharmacogenes in a discovery cohort of 112 patients (35 AT-DILI patients and 77 controls) receiving AT treatment for active tuberculosis. Pharmacogenome-wide association analysis was also conducted using 1048 population controls (Korea1K). NAT2 and ATP7B genotypes were analyzed in a replication cohort of 165 patients (37 AT-DILI patients and 128 controls) to validate the effects of both risk genotypes. NAT2 ultraslow acetylators (UAs) were found to have a greater risk of AT-DILI than other genotypes (odds ratio [OR] 5.6 [95% confidence interval; 2.5-13.2], P = 7.2 × 10-6). The presence of ATP7B gene 832R/R homozygosity (rs1061472) was found to co-occur with NAT2 UA in AT-DILI patients (P = 0.017) and to amplify the risk in NAT2 UA (OR 32.5 [4.5-1423], P = 7.5 × 10-6). In vitro experiments using human liver-derived cell lines (HepG2 and SNU387 cells) revealed toxic synergism between INH and Cu, which were strongly augmented in cells with defective NAT2 and ATP7B activity, leading to increased mitochondrial reactive oxygen species generation, mitochondrial dysfunction, DNA damage, and apoptosis. These findings link the co-occurrence of ATP7B and NAT2 genotypes to the risk of INH-induced hepatotoxicity, providing novel mechanistic insight into individual AT-DILI susceptibility. Yoon et al. showed that individuals who carry NAT2 UAs and ATP7B 832R/R genotypes are at increased risk of developing isoniazid hepatotoxicity, primarily due to the increased synergistic toxicity between isoniazid and copper, which exacerbates mitochondrial dysfunction-related apoptosis.

The efficacy and safety of high-dose isoniazid-containing therapy for multidrug-resistant tuberculosis: a systematic review and meta-analysis

Objectives: Accumulating evidence are available on the efficacy of high-dose isoniazid (INH) for multidrug-resistant tuberculosis (MDR-TB) treatment. We aimed to perform a systematic review and meta-analysis to compare clinical efficacy and safety outcomes of high-dose INH- containing therapy against other regimes. Methods: We searched the following databases PubMed, Embase, Scopus, Web of Science, CINAHL, the Cochrane Library, and ClinicalTrials.gov. We considered and included any studies comparing treatment success, treatment unsuccess, or adverse events in patients with MDR-TB treated with high-dose INH (>300 mg/day or >5 mg/kg/day). Results: Of a total of 3,749 citations screened, 19 studies were included, accounting for 5,103 subjects, the risk of bias was low in all studies. The pooled treatment success, death, and adverse events of high-dose INH-containing therapy was 76.5% (95% CI: 70.9%-81.8%; I2: 92.03%), 7.1% (95% CI: 5.3%-9.1%; I2: 73.75%), and 61.1% (95% CI: 43.0%-77.8%; I2: 98.23%), respectively. The high-dose INH administration is associated with significantly higher treatment success (RR: 1.13, 95% CI: 1.04-1.22; p < 0.01) and a lower risk of death (RR: 0.45, 95% CI: 0.32-0.63; p < 0.01). However, in terms of other outcomes (such as adverse events, and culture conversion rate), no difference was observed between high-dose INH and other treatment options (all p > 0.05). In addition, no publication bias was observed. Conclusion: In MDR-TB patients, high-dose INH administration is associated with a favorable outcome and acceptable adverse-event profile. Systematic review registration: identifier CRD42023438080.

Genetic Polymorphisms of UDP-Glucuronosyltransferases and Susceptibility to Antituberculosis Drug-Induced Liver Injury: A Systematic Review and Meta-Analysis

Methods

The PRISMA statement was strictly followed, and the protocol was registered in PROSPERO (CRD42022339317). The PICOS framework was used: patients received antituberculosis treatment, UGTs polymorphisms (mutants), UGTs polymorphisms (wild), AT-DILI, and case-control studies. Eligible studies were searched through nine databases up to April 27, 2022. The study's qualities were assessed by the revised Little's recommendations. Meta-analysis was conducted with a random-effects model using odds ratios (ORs) with 95% confidence intervals (95% CIs) as the effect size.

Results

Twelve case-control studies with 2128 cases and 4338 controls were included, and 32 single nucleotide polymorphisms (SNPs) in the seven UGT genes have been reported in Chinese and Korean. All studies were judged as high quality. The pooled results indicated that UGT1A1 rs3755319 (AC vs. AA, OR = 1.454, 95% CI: 1.100-1.921, P = 0.009), UGT2B7 rs7662029 (G vs. A, OR = 1.547, 95% CI: 1.249-1.917, P < 0.0001; GG + AG vs. AA, OR = 2.371, 95% CI: 1.779-3.160, P < 0.0001; AG vs. AA, OR = 2.686, 95% CI: 1.988-3.627, P < 0.0001), and UGT2B7 rs7439366 (C vs. T, OR = 0.585, 95% CI: 0.477-0.717, P < 0.0001; CC + TC vs. TT, OR = 0.347, 95% CI: 0.238-0.506, P < 0.0001; CC vs. TC + TT, OR = 0.675, 95% CI: 0.507-0.898, P = 0.007) might be associated with the risk of AT-DILI.

Conclusions

The polymorphisms of UGT1A1 rs3755319, UGT2B7 rs7662029, and UGT2B7 rs7439366 were significantly associated with AT-DILI susceptibility. However, this conclusion should be interpreted with caution due to the low number of studies and the relatively small sample size.

A Case Series on Post-COVID Tuberculosis: An Underrated Duo of COVID-19 and Tuberculosis

In India, tuberculosis (TB) has the second highest disease burden following diabetes mellitus. During the COVID-19 pandemic, there was a surge of several opportunistic infections. In this case series, we report five patients, including three adults and two adolescents, who have developed various forms of TB disease after symptomatic COVID-19 pneumonia. The average time for development of post-COVID TB was 48 days. Adolescent patients have developed disseminated TB, which can be due to COVID-19-induced immunological injury or its treatment-related immune suppression. All the adult patients had high CT severity scores (CTSS) and required the administration of intravenous steroids during their COVID-19 pneumonia. Various presentations of TB were secondary spontaneous pneumothorax, miliary TB, consolidation, and nodular infiltrates. One patient had a drug-induced liver injury, which complicated the treatment of that patient. Factors that may contribute to the development of post-COVID TB are diabetes mellitus, increased severity of COVID-19 pneumonia manifested by CTSS, and administration of intravenous steroids. Bidirectional screening of TB had to be done when patients present with symptoms of COVID-19 pneumonia.

Metabolic Disorders Are Associated With Drug-Induced Liver Injury During Antituberculosis Treatment: A Multicenter Prospective Observational Cohort Study in Korea

Background

Drug-induced liver injury (DILI) may lead to the discontinuation of antituberculosis (anti-TB) treatment (ATT). Some studies have suggested that metabolic disorders increase the risk of DILI during ATT. This study aimed to identify risk factors for DILI, particularly metabolic disorders, during ATT.

Methods

A multicenter prospective observational cohort study to evaluate adverse events during ATT was conducted in Korea from 2019 to 2021. Drug-susceptible patients with TB who had been treated with standard ATT for 6 months were included. The patients were divided into 2 groups depending on the presence of 1 or more metabolic conditions, such as insulin resistance, hypertension, obesity, and dyslipidemia. We monitored ATT-related adverse events, including DILI, and treatment outcomes. The incidence of DILI was compared between individuals with and without metabolic disorders, and related factors were evaluated.

Results

Of 684 patients, 52 (7.6%) experienced DILI, and 92.9% of them had metabolic disorders. In the multivariable analyses, underlying metabolic disorders (adjusted hazard ratio [aHR], 2.85; 95% CI, 1.01-8.07) and serum albumin <3.5 g/dL (aHR, 2.26; 95% CI, 1.29-3.96) were risk factors for DILI during ATT. In the 1-month landmark analyses, metabolic disorders were linked to an elevated risk of DILI, especially significant alanine aminotransferase elevation. The treatment outcome was not affected by the presence of metabolic disorders.

Conclusions

Patients with metabolic disorders have an increased risk of ATT-induced liver injury compared with controls. The presence of metabolic disorders and hypoalbuminemia adversely affects the liver in patients with ATT.

Time of Liver Function Abnormal Identification on Prediction of the Risk of Anti-tuberculosis-induced Liver Injury

BACKGROUND AND AIMS

Anti-tuberculosis (anti-TB) drug-induced liver injury (AT-DILI) is the most common side effect in patients who received anti-TB therapy. AT-DILI management includes monitoring liver function until symptoms arise in patients without high-risk factors for liver damage. The present study aimed to investigate the effect of liver function test (LFT) abnormal identification on the risk of DILI, including liver failure and anti-TB drug resistance in patients without high-risk factors.

METHODS

A total of 399 patients without high-risk factors for liver damage at baseline and who experienced LFT abnormal during the 6 months of first-line anti-TB treatment were enrolled. The Roussel Uclaf Causal Relationship Assessment Method (RUCAM, 2016) was applied in suspected DILI. The correlations between the time of LFT abnormal identification and DILI, liver failure, and anti-TB drug resistance were analyzed by smooth curve fitting and multivariable logistic regression models.

RESULTS

Among all study patients, 131 met the criteria for DILI with a mean RUCAM causality score of 8.86±0.63. 26/131 and 105/131 were in the probable grading and highly probable grading, respectively. The time of abnormal LFT identification was an independent predictor of DILI, liver failure, and anti-TB drug resistance in the crude model and after adjusting for other risk patient factors. The time of abnormal LFT identification was positively correlated with DILI, liver failure, and anti-TB drug resistance. The late identification group (>8 weeks) had the highest risk of DILI, followed by liver failure compared with the other two groups.

CONCLUSIONS

The time to identification of LFT was positively correlated with DILI, liver failure, and anti-TB drug resistance. The risk of DILI and liver failure was significantly increased in the late identification group with abnormal LFT identified after 8 weeks compared with 4 and 8 weeks. Early monitoring of LFT is recommended for patients without the high-risk factor of DILI after anti-TB treatment is initiated.

Factors associated with loss to follow-up before and after treatment initiation among patients with tuberculosis: A 5-year observation in China

Background

Loss to follow-up (LTFU) is a significant barrier to the completion of anti-tuberculosis (TB) treatment and a major predictor of TB-associated deaths. Currently, research on LTFU-related factors in China is both scarce and inconsistent.

Methods

We collected information from the TB observation database of the National Clinical Research Center for Infectious Diseases. The data of all patients who were documented as LTFU were assessed retrospectively and compared with those of patients who were not LTFU. Descriptive epidemiology and multivariable logistic regression analyses were conducted to identify the factors associated with LTFU.

Results

A total of 24,265 TB patients were included in the analysis. Of them, 3,046 were categorized as LTFU, including 678 who were lost before treatment initiation and 2,368 who were lost afterwards. The previous history of TB was independently associated with LTFU before treatment initiation. Having medical insurance, chronic hepatitis or cirrhosis, and providing an alternative contact were independent predictive factors for LTFU after treatment initiation.

Conclusion

Loss to follow-up is frequent in the management of patients with TB and can be predicted using patients' treatment history, clinical characteristics, and socioeconomic factors. Our research illustrates the importance of early assessment and intervention after diagnosis. Targeted measures can improve patient engagement and ultimately treatment adherence, leading to better health outcomes and disease control.

Building sustainable clinical trial sites in Sub-Saharan Africa through networking, infrastructure improvement, training and conducting clinical studies: The PanACEA approach

INTRODUCTION

The Pan-African Consortium for the Evaluation of Anti-Tuberculosis Antibiotics (PanACEA) was designed to build tuberculosis (TB) trial capacity whilst conducting clinical trials on novel and existing agents to shorten and simplify TB treatment. PanACEA has now established a dynamic network of 11 sub-Saharan clinical trial sites and four European research institutions.

OBJECTIVES

In 2011, a capacity development program, funded by the European & Developing Countries Clinical Trials Partnership (EDCTP), was launched with four objectives, aiming at strengthening collaborating TB research sites to reach the ultimate goal of becoming self-sustainable institutions: networking; training; conducting clinical trials; and infrastructure scaling-up of sites.

METHODS

Assessment in six sub-Saharan TB-endemic countries (Gabon, Kenya, South Africa, Tanzania, Uganda and Zambia) were performed through a structured questionnaire, site visits, discussion with the PanACEA consortium, setting of milestones and identification of priorities and followed-up with evaluations of each site. The results of this needs-based assessment was then translated into capacity development measures.

RESULTS

In the initial phase, over a four-year period (March 2011 - June 2014), the programme scaled-up six sites; conducted a monitoring training program for 11 participants; funded five MSc and four PhD students, fostering gender balance; conducted four epidemiological studies; supported sites to conduct five Phase II studies and formed a sustainable platform for TB research (panacea-tb.net).

CONCLUSION

Our experience of conducting TB clinical trials within the PanACEA programme environment of mentoring, networking and training has provided a sound platform for establishing future sustainable research centres. Our goal of facilitating emergent clinical TB trial sites to better initiate and lead research activities has been mostly successful.

Circulatory Inflammatory Mediators in the Prediction of Anti-Tuberculous Drug-Induced Liver Injury Using RUCAM for Causality Assessment

BACKGROUND

Anti-tuberculous (TB) medications are common causes of drug-induced liver injury (DILI). Limited data are available on systemic inflammatory mediators as biomarkers for predicting DILI before treatment. We aimed to select predictive markers among potential candidates and to formulate a predictive model of DILI for TB patients.

METHODS

Adult active TB patients from a prospective cohort were enrolled, and all participants received standard anti-tuberculous treatment. Development of DILI, defined as ≥5× ULN for alanine transaminase or ≥2.6× ULN of total bilirubin with causality assessment (RUCAM, Roussel Uclaf causality assessment method), was regularly monitored. Pre-treatment plasma was assayed for 15 candidates, and a set of risk prediction scores was established using Cox regression and receiver-operating characteristic analyses.

RESULTS

A total of 19 (7.9%) in 240 patients developed DILI (including six carriers of hepatitis B virus) following anti-TB treatment. Interleukin (IL)-22 binding protein (BP), interferon gamma-induced protein 1 (IP-10), soluble CD163 (sCD163), IL-6, and CD206 were significant univariable factors associated with DILI development, and the former three were backward selected as multivariable factors, with adjusted hazards of 0.20 (0.07-0.58), 3.71 (1.35-10.21), and 3.28 (1.07-10.06), respectively. A score set composed of IL-22BP, IP-10, and sCD163 had an improved area under the curve of 0.744 (p < 0.001).

CONCLUSIONS

Pre-treatment IL-22BP was a protective biomarker against DILI development under anti-TB treatment, and a score set by additional risk factors of IP-10 and sCD163 employed an adequate DILI prediction.

Predicting Antituberculosis Drug-Induced Liver Injury Using an Interpretable Machine Learning Method: Model Development and Validation Study

Background

Tuberculosis (TB) is a pandemic, being one of the top 10 causes of death and the main cause of death from a single source of infection. Drug-induced liver injury (DILI) is the most common and serious side effect during the treatment of TB.

Objective

We aim to predict the status of liver injury in patients with TB at the clinical treatment stage.

Methods

We designed an interpretable prediction model based on the XGBoost algorithm and identified the most robust and meaningful predictors of the risk of TB-DILI on the basis of clinical data extracted from the Hospital Information System of Shenzhen Nanshan Center for Chronic Disease Control from 2014 to 2019.

Results

In total, 757 patients were included, and 287 (38%) had developed TB-DILI. Based on values of relative importance and area under the receiver operating characteristic curve, machine learning tools selected patients’ most recent alanine transaminase levels, average rate of change of patients’ last 2 measures of alanine transaminase levels, cumulative dose of pyrazinamide, and cumulative dose of ethambutol as the best predictors for assessing the risk of TB-DILI. In the validation data set, the model had a precision of 90%, recall of 74%, classification accuracy of 76%, and balanced error rate of 77% in predicting cases of TB-DILI. The area under the receiver operating characteristic curve score upon 10-fold cross-validation was 0.912 (95% CI 0.890-0.935). In addition, the model provided warnings of high risk for patients in advance of DILI onset for a median of 15 (IQR 7.3-27.5) days.

Conclusions

Our model shows high accuracy and interpretability in predicting cases of TB-DILI, which can provide useful information to clinicians to adjust the medication regimen and avoid more serious liver injury in patients.

Investigation of Zinc Supplement Impact on the Serum Biochemical Parameters in Pulmonary Tuberculosis: A Double Blinded Placebo Control Trial

BACKGROUND

Zinc (Zn) is nutritionally essential trace element, and thus deficiency may severely affect human health. The results of cross-sectional studies indicate that micronutrient deficiencies are common in patients with tuberculosis. Our goal is to investigate whether Zn supplementation can increase the effects of anti-TB treatment or not.

METHODS

Patients with newly diagnosed tuberculosis were divided in to 2 groups. One group (n= 37) received capsule contains 50 mg of elemental zinc (as zinc sulfate) for 6 months every other day (micronutrient group) and Group II (n= 37) received placebo. Both groups received the same anti-tuberculosis treatment recommended by the WHO. Clinical examination, BMI, chest X-ray, direct sputum examination, assessment of serum zinc levels (by atomic absorption spectrophotometry), and biochemical markers serum concentration (by using an RA1000 AutoAnalyzer) were carried out before and after 2- and 6-months anti-tuberculosis treatment.

RESULTS

Plasma zinc concentrations in the micronutrient group was higher than placebo group After treatment. In the placebo group increasing in SGOT and SGPT concentrations were significantly higher than micronutrient group after 2 months of treatment (p< 0.05). The significant changes (p< 0.05) were observed on the serum levels of total protein, albumin. Alkaline phosphatase (ALP) levels, serum creatinine, uric acid and urea in groups were not significantly different.

CONCLUSION

Zinc supplementation results in earlier sputum smear conversion in the micronutrient group during the first 6 weeks. Increased body weight and serum zinc and serum albumin and decrease in total protein was observed in the micronutrient group.

Incidence and risk factors of anti-tuberculosis drug induced liver injury (DILI): Large cohort study involving 4652 Chinese adult tuberculosis patients

BACKGROUND AND AIMS

Anti-tuberculosis drugs remain as an important cause of drug-induced liver injury (DILI) worldwide. Adverse drug reactions reduce the effectiveness of treatment. We aimed to determine the incidence and risk factors associated with anti-tuberculosis DILI (ATDILI).

METHODS

Using established criteria and causality assessment methods, risk factors for ATDILI were identified in a contemporary cohort and validated in another cohort prospectively. Independent determinants of ATDILI were identified using Cox regression analysis.

RESULTS

In the derivation cohort (n = 3155), 170 (5.4%) developed ATDILI of which 27 (15.9%) developed jaundice; 9(5.3%) developed acute liver failure (ALF) and 3 died. Among HBsAg positive patients, 11/27 (40.7%) of ATDILI developed after 3 months of starting treatment. In addition, of 218 (6.9%) who developed raised alanine transferase (ALT) levels ≥3 times upper limit normal, 193 (88.5%) resolved and 25 (11.4%) progressed to DILI. Age (HR = 1.014, 95% CI: 1.005-1.023), baseline ALT (HR = 1.014, 95% CI: 1.003-1.024), haemoglobin (HR = 1.011, 95% CI: 1.002-1.020) and HBsAg positivity (HR = 1.516, 95% CI: 1.004-2.290) were independent risk factors for DILI. In the second cohort (n = 1497) of which 85 (5.7%) developed ATDILI. Age (HR = 1.029, 95% CI: 1.003-1.056), baseline AST (HR = 1.036, 95% CI: 1.010-1.062), previous TB treatment (HR = 3.894, 95% CI: 1.304-11.625) and active drinking (HR = 3.624, 95% CI: 1.147-11.454) were risk factors for developing jaundice.

CONCLUSION

Elevation of ALT of ≥3 × ULN during anti-TB treatment resolves in the vast majority without developing serious consequences. In two cohorts involving 4652 patients, incidence of ALF and death because of ATDILI are low. Age, baseline ALT, haemoglobin and HBsAg positivity are risk factors for the development of DILI and these inform monitoring and management of these patients.

The Indian Network of Drug-Induced Liver Injury: Etiology, Clinical Features, Outcome and Prognostic Markers in 1288 Patients

BACKGROUND

Etiology of and outcomes following idiosyncratic drug-induced liver injury (DILI) vary geographically. We conducted a prospective study of DILI in India, from 2013 to 2018 and summarize the causes, clinical features, outcomes and predictors of mortality.

METHODS

We enrolled patients with DILI using international DILI expert working group criteria and Roussel Uclaf causality assessment method. Follow-up was up to 3 months from onset of DILI or until death. Multivariate logistics regression was carried out to determine predictors of non-survival.

RESULTS

Among 1288 patients with idiosyncratic DILI, 51.4% were male, 68% developed jaundice, 68% required hospitalization and 8.2% had co-existing HIV infection. Concomitant features of skin reaction, ascites, and encephalopathy (HE) were seen in 19.5%, 16.4%, and 10% respectively. 32.4% had severe disease. Mean MELD score at presentation was 18.8 ± 8.8. Overall mortality was 12.3%; 65% in those with HE, 17.6% in patients who fulfilled Hy's law, and 16.6% in those that developed jaundice. Combination anti-TB drugs (ATD) 46.4%, complementary and alternative medicines (CAM) 13.9%, anti-epileptic drugs (AED) 8.1%, non-ATD antimicrobials 6.5%, anti-metabolites 3.8%, anti-retroviral drugs (ART)3.5%, NSAID2.6%, hormones 2.5%, and statins 1.4% were the top 9 causes. Univariate analysis identified, ascites, HE, serum albumin, bilirubin, creatinine, INR, MELD score (p < 0.001), transaminases (p < 0.04), and anti-TB drugs (p = 0.02) as predictors of non-survival. Only serum creatinine (p = 0.017), INR (p < 0.001), HE (p < 0.001), and ascites (p = 0.008), were significantly associated with mortality on multivariate analysis. ROC yielded a C-statistic of 0.811 for MELD and 0.892 for combination of serum creatinine, INR, ascites and HE. More than 50 different agents were associated with DILI. Mortality varied by drug class: 15% with ATD, 13.6% with CAM, 15.5% with AED, 5.8% with antibiotics.

CONCLUSION

In India, ATD, CAM, AED, anti-metabolites and ART account for the majority of cases of DILI. The 3-month mortality was approximately 12%. Hy's law, presence of jaundice or MELD were predictors of mortality.

Drug-induced liver injury: Asia Pacific Association of Study of Liver consensus guidelines

Idiosyncratic drug-induced liver injury mimics acute and chronic liver disease. It is under recognized and underrecognised because of the lack of pathognomonic diagnostic serological markers. Its consequences may vary from being asymptomatic to self-limiting illness to severe liver injury leading to acute liver failure. Its incidence is likely to be more common in Asia than other parts of the world, mainly because of hepatotoxicity resulting from the treatment of tuberculosis disease and the ubiquitous use of traditional and complimentary medicines in Asian countries. This APASL consensus guidelines on DILI is a concise account of the various aspects including current evidence-based information on DILI with special emphasis on DILI due to antituberculosis agents and traditional and complementary medicine use in Asia.

Prospective study of ALDH1A1 gene polymorphisms associated with antituberculosis drug-induced liver injury in western Chinese Han population

Antituberculosis drug-induced liver injury (ATDILI) has received increasing attention globally, which may limit the effectiveness of antituberculosis (anti-TB) treatment. Many host genetic determinants of ATDILI have been identified recently. As little knowledge is currently available about the association between aldehyde dehydrogenase 1 family member A1 (ALDH1A1) polymorphisms and ATDILI, the association between their variants and the susceptibility to ATDILI was investigated. A total of 747 patients with TB treated by first-line anti-TB drugs were prospectively enrolled at West China Hospital. Genomic DNA was extracted from the peripheral blood sample of each patient and seven single-nucleotide polymorphisms (SNPs) of ALDH1A1 gene were screened and genotyped with a custom-designed 2×48-plex SNP Scan TM kit. The patients were followed up monthly to monitor the development of ATDILI. The C allele and the CA genotype of rs7852860 were significantly associated with an elevated risk for ATDILI (p = .006 and 0.005, respectively), which was consistent with the results in the dominant and additive models. No allele, genotype, or genetic model of the other six SNPs (rs3764435, rs348471, rs63319, rs610529, rs7027604, rs8187876) were found to be associated with susceptibility to ATDILI. The findings first demonstrate that rs7852860 variants in ALDH1A1 gene is associated with susceptibility to ATDILI in the Chinese Han population. Validation studies with larger sample sizes and other ethnic groups are needed to confirm the findings.

Genetic Polymorphisms of Delta-Like 1 Homolog Influence the Susceptibility to Antituberculosis Drug-Induced Hepatotoxicity

This study was designed to investigate the relationship between Delta-like 1 homolog (DLK1) polymorphisms and the occurrence of antituberculosis drug-induced hepatotoxicity (ATDH) in the Western Chinese Han population. A total of 746 tuberculosis patients including 118 ATDH cases and 628 non-ATDH cases were enrolled from West China Hospital of Sichuan University during 2016-2018. Ten single nucleotide polymorphisms (rs11160604, rs7149242, rs7141210, rs7155375, rs876374, rs57098752, rs2400940, rs12431758, rs4900472, and rs6575802) within DLK1 were studied by the improved multiplex ligation detection reaction method genotyping technology assay. It was found that G allele of rs11160604 was associated with an increased risk for ATDH (p = 0.001) and G allele of rs4900472 showed a protective effect for ATDH (p = 0.030). Recessive model and dominant model of rs11160604 were observed as a risk factor for ATDH predisposition, whereas the recessive model of rs4900472 was a protective one. Moreover, the interaction genetic model composed of rs11160604, rs57098752, and rs12431758 showed a combined effect for the occurrence of ATDH. Our finding was a novel one indicating that the G allele of DLK1 rs11160604 might serve as a hazard for the development of ATDH in the Western Chinese Han population.

Genetic Risk Factors in Drug-Induced Liver Injury Due to Isoniazid-Containing Antituberculosis Drug Regimens

Drug-induced liver injury (DILI) is a complication of treatment with antituberculosis (TB) drugs, especially in isoniazid (INH)-containing regimens. To investigate genetic risk factors, we performed a genomewide association study (GWAS) involving anti-TB DILI cases (55 Indian and 70 European) and controls (1,199 Indian and 10,397 European). Most cases were treated with a standard anti-TB drug regimen; all received INH. We imputed single nucleotide polymorphism and HLA genotypes and performed trans-ethnic meta-analysis on GWAS and candidate gene genotypes. GWAS found one significant association (rs117491755) in Europeans only. For HLA, HLA-B*52:01 was significant (meta-analysis odds ratio (OR) 2.67, 95% confidence interval (CI) 1.63-4.37, P = 9.4 × 10^-5 ). For N-acetyltransferase 2 (NAT2), NAT2*5 frequency was lower in cases (OR 0.69, 95% CI 0.57-0.83, P = 0.01). NAT2*6 and NAT2*7 were more common, with homozygotes for NAT2*6 and/or NAT2*7 enriched among cases (OR 1.89, 95% CI 0.84-4.22, P = 0.004). We conclude HLA genotype makes a small contribution to TB drug-related DILI and that the NAT2 contribution is complex, but consistent with previous reports when differences in the metabolic effect of NAT2*5 compared with those of NAT2*6 and NAT2*7 are considered.

Predicting drug-induced liver injury from anti-tuberculous medications by early monitoring of liver tests

OBJECTIVE

Tuberculosis Drug Induced Liver Injury (TB-DILI) is a common and potentially severe complication associated with anti-tuberculous treatment (ATT). Optimal liver test monitoring for standard TB medication has not been established. We describe the predictive value of pre-treatment liver tests (LTs) and at 2-weeks after initiation of ATT for the detection of TB-DILI.

METHODS

Patients initiating ATT were monitored with routine LTs pre-treatment and after 2-weeks. Logistic regression models were constructed to retrospectively identify pre-treatment variables associated with 'late' TB-DILI (>2 weeks after treatment initiation) and whether pre-treatment and 2-week alanine aminotransferase (ALT) levels could predict late TB-DILI.

RESULTS

1247 patients with active tuberculosis managed at 5 sites across north west London between January 2015 and December 2018 were monitored with routine LTs. 103 cases (8.3%) of ATT-associated DILI were diagnosed. 60 cases (58.3%) of TB-DILI occurred later than 2-weeks. The risk of late TB-DILI was 2.2-fold greater for every 30 U/L increment in ALT pre-treatment (OR 2.16, 95% CI 1.38-3.29 p<0.001) and 2.1-fold greater for every 30 U/L increment in ALT gradient at 2-weeks (OR 2.06, 95% CI 1.52-2.76 p<0.001).

CONCLUSION

Routine 2-week LTs capture early TB-DILI and may be valuable in predicting late TB-DILI in patients on ATT.

Drug exposure and minimum inhibitory concentration predict pulmonary tuberculosis treatment response

BACKGROUND

Prospective studies correlating pharmacokinetic/pharmacodynamic (PK/PD) indices to clinical responses are urgently needed. This study aimed to find clinically relevant PK/PD thresholds that can be used for treatment optimization.

METHODS

Pharmacokinetic sampling and minimum inhibitory concentration (MIC) measurements were performed for culture-confirmed tuberculosis patients. Classification and regression tree (CART) analysis was applied to obtain PK and/or PD thresholds for first-line drugs predictive of two-week/month culture conversion, treatment outcome determined at 6-8 months, acute kidney injury (AKI) and drug-induced liver injury (DILI). Least absolute shrinkage and selection operator (LASSO) logistic regression was used for model development and validation.

RESULTS

Finally, 168 and 52 patients with tuberculosis were included in development and validation cohort for analysis, respectively. Area under concentration-time curve (AUC)/MIC below CART-derived thresholds for pyrazinamide of 8.42, pyrazinamide of 2.79 or rifampicin of 435.45 were the predominant predictors of two-week culture conversion, two-month culture conversion or treatment success, respectively. Isoniazid AUC above 21.78 mg·h/L or rifampicin AUC above 82.01 mg·h/L were predictive of DILI or AKI during TB treatment. The predictive performance of trained LASSO models in validation cohort was evaluated by receiver operating characteristic curves and ranged from 0.625 to 0.978.

CONCLUSIONS

PK/PD indices and drug exposure of anti-TB drugs were associated with clinical outcome and adverse events. The effect of CART-derived thresholds for individualized dosing on treatment outcome should be studied in a randomized controlled trial.

Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital

Tuberculosis (TB) in the elderly (>65 years old) has increasingly become a global health problem. It has long been recognized that older people are vulnerable to developing tuberculosis. We retrospectively evaluated data from patients older than 65 years diagnosed with pulmonary TB admitted to the National Institute for Infectious Diseases L. Spallanzani, Rome, Italy, from 1 January 2016 to 31 December 2019. One hundred and six consecutive patients were diagnosed with pulmonary TB and 68% reported at least one comorbidity and 44% at least one of the TB risk-factors. Out of the 26 elderly patients who reported an adverse event, having risk factors for TB (O.R. (Odds Ratios) = 1.45; 95% CI 1.12-3.65) and the presence of cavities on Chest X-rays (O.R. = 1.42; 95% CI 1.08-2.73) resulted in being more likely to be associated with adverse events in elderly patients. Having weight loss (O.R. = 1.31; 95% CI 1.08-1.55) and dyspnea (O.R. = 1.23; 95% CI 1.13-1.41) resulted in being significant predictors of unsuccessful treatment outcome in elderly patients. Older people with TB represent a vulnerable group, with high mortality rate, with a challenging diagnosis. Hospitalizations in tertiary referral hospital with clinical expertise in TB management can be useful to improve the outcome of these fragile patients.

High Rates of Drug-induced Liver Injury in People Living With HIV Coinfected With Tuberculosis (TB) Irrespective of Antiretroviral Therapy Timing During Antituberculosis Treatment: Results From the Starting Antiretroviral Therapy at Three Points in TB Trial

BACKGROUND

New onset or worsening drug-induced liver injury challenges coinfected patients on antiretroviral therapy (ART) initiation during antituberculosis (TB) treatment.

METHODS

Post hoc analysis within a randomized trial, the Starting Antiretroviral Therapy at Three Points in Tuberculosis trial, was conducted. Patients were randomized to initiate ART either early or late during TB treatment or after TB treatment completion. Liver enzymes were measured at baseline, 6-month intervals, and when clinically indicated.

RESULTS

Among 642 patients enrolled, the median age was 34 years (standard deviation, 28-40), and 17.6% had baseline CD4+ cell counts <50 cells/mm3. Overall, 146/472 patients (52, 47, and 47: early, late, and sequential arms) developed new-onset liver injury following TB treatment initiation. The incidence of liver injury post-ART initiation in patients with CD4+ cell counts <200 cells/mm3 and ≥200 cells/ mm3 was 27.4 (95% confidence interval [CI], 18.0-39.8), 19.0 (95% CI, 10.9-30.9), and 18.4 (95% CI, 8.8-33.8) per 100 person-years, and 32.1 (95% CI, 20.1-48.5), 11.8 (95% CI, 4.3-25.7), and 28.2 (95% CI, 13.5-51.9) per 100 person-years in the early, late integrated, and sequential treatment arms, respectively. Severe and life-threatening liver injury occurred in 2, 7, and 3 early, late, and sequential treatment arm patients, respectively. Older age and hepatitis B positivity predicted liver injury.

CONCLUSIONS

High incidence rates of liver injury among cotreated human immunodeficiency virus (HIV)-TB coinfected patients were observed. Clinical guidelines and policies must provide guidance on frequency of liver function monitoring for HIV-TB coinfected patients.

New drugs to treat difficult tuberculous and nontuberculous mycobacterial pulmonary disease

PURPOSE OF REVIEW

Treatment of drug-sensitive tuberculosis (TB) is effective, whereas that of multidrug-resistant and extensively drug-resistant TB as well as nontuberculous mycobacterial (NTM) disease are less so. Therapy in general requires good adherence to potentially toxic drug regimens over prolonged periods. Poor adherence is associated with resistance development and poor outcome. This review will present promising new treatments, both new drugs and regimens, for difficult mycobacterial pulmonary infections.

RECENT FINDINGS

A number of new and repurposed drugs including bedaquiline, delamanid, pretomanid, linezolid and clofazimine, and drug regimens, such as the The Evaluation of a Standard Treatment Regimen of Anti-tuberculosis Drugs for Patients With MDR-TB (STREAM) trial regimens, are currently progressing from basic research through clinical trials.

SUMMARY

Drug-Induced Liver Injury from Anti-Tuberculosis Treatment: A Retrospective Cohort Study

Background

The aim of this study was to investigate the clinical characteristics and the risk factors associated with anti-tuberculosis (anti-TB) drug-induced liver injury (DILI).

Material/Methods

This retrospective study enrolled 140 hospitalized patients diagnosed with anti-TB DILI during January 2009 to December 2015. We assessed the baseline characteristics and performed regular follow-up up to the 24^th week to assess the possible risk factors associated with the condition.

Results

The study population was 58.6% male and 41.4% female patients; 20.7% were diagnosed with grades 4–5 DILI and 79.3% with grades 1–3 DILI. Female patients were significantly more likely to be diagnosed with grades 4–5 DILI than with grades 1–3 DILI (58.6% vs. 36.9%, p=0.036). Patients treated with a multidrug anti-TB regimen were more commonly affected with grades 4–5 DILI (86.2% vs. 68.5%, p=0.045). A significant number of patients who reinitiated anti-TB therapy suffered severe liver injury in comparison to patients with grades 1–3 DILI (41.4% vs. 10.8%, P<.001). Laboratory examinations revealed significantly higher values for total bilirubin (TBL), International normalized ratio (INR), and Hy’s law (P<.001) in the grades 4–5 group compare to the grades 1–3 group.

Conclusions

Female gender, combination therapy for antitubercular drugs (isoniazid, rifampicin and pyrazinamide), re-challenge were the risk factors associated with the severity of anti-TB DILI.

The Prevalence and Demographic Risk Factors for Latent Tuberculosis Infection (LTBI) Among Healthcare Workers in Semarang, Indonesia

Purpose

To determine the prevalence and demographic risk factors for latent tuberculosis infection (LTBI) among healthcare workers in Semarang, Indonesia.

Methods

A cross-sectional study involving 195 healthcare workers from 34 primary health centers was conducted from August to October 2019. The relationship between independent variables and dependent variables was analyzed using a multivariable logistic regression analysis.

Results

The prevalence of LTBI among healthcare workers in this study was 23.6%. Comorbidities were the only risk factor for LTBI identified among other risk factors (OR=3.39, 95% CI: 0.99–11.62, p=0.04). Other demographic factors such as age (OR=0.93, 95% CI: 0.45–1.92, p=0.839), gender (OR=0.79, 95% CI: 0.23–2.72, p=0.708, smoking habits (OR=2.54, 95% CI: 0.52–12.38, p=0.247), and length of work (OR=1.43, 95% CI: 0.70–2.91, p=0.331) were not significant risk factors for LTBI.

Conclusion

Healthcare workers suffering from comorbidity have a high risk for tuberculosis infection, and should not work in areas where they would be exposed to patients with tuberculosis. Healthcare workers need to apply occupational safety standards during contact with TB patients or specimens to minimize the disease transmission.

Bedaquiline, moxifloxacin, pretomanid, and pyrazinamide during the first 8 weeks of treatment of patients with drug-susceptible or drug-resistant pulmonary tuberculosis: a multicentre, open-label, partially randomised, phase 2b trial

BACKGROUND

New anti-tuberculosis regimens that are shorter, simpler, and less toxic than those that are currently available are needed as part of the global effort to address the tuberculosis epidemic. We aimed to investigate the bactericidal activity and safety profile of combinations of bedaquiline, pretomanid, moxifloxacin, and pyrazinamide in the first 8 weeks of treatment of pulmonary tuberculosis.

METHODS

In this multicentre, open-label, partially randomised, phase 2b trial, we prospectively recruited patients with drug-susceptible or rifampicin-resistant pulmonary tuberculosis from seven sites in South Africa, two in Tanzania, and one in Uganda. Patients aged 18 years or older with sputum smear grade 1+ or higher were eligible for enrolment, and a molecular assay (GeneXpert or MTBDRplus) was used to confirm the diagnosis of tuberculosis and to distinguish between drug-susceptible and rifampicin-resistant tuberculosis. Patients who were HIV positive with a baseline CD4 cell count of less than 100 cells per uL were excluded. Patients with drug-susceptible tuberculosis were randomly assigned (1:1:1) using numbered treatment packs with sequential allocation by the pharmacist to receive 56 days of treatment with standard tuberculosis therapy (oral isoniazid, rifampicin, pyrazinamide, and ethambutol; HRZE), or pretomanid (oral 200 mg daily) and pyrazinamide (oral 1500 mg daily) with either oral bedaquiline 400 mg daily on days 1-14 then 200 mg three times per week (B_loadPaZ) or oral bedaquiline 200 mg daily (B₂₀₀PaZ). Patients with rifampicin-resistant tuberculosis received 56 days of the B₂₀₀PaZ regimen plus moxifloxacin 400 mg daily (BPaMZ). All treatment groups were open label, and randomisation was not stratified. Patients, trial investigators and staff, pharmacists or dispensers, laboratory staff (with the exception of the mycobacteriology laboratory staff), sponsor staff, and applicable contract research organisations were not masked. The primary efficacy outcome was daily percentage change in time to sputum culture positivity (TTP) in liquid medium over days 0-56 in the drug-susceptible tuberculosis population, based on non-linear mixed-effects regression modelling of log₁₀ (TTP) over time. The efficacy analysis population contained patients who received at least one dose of medication and who had efficacy data available and had no major protocol violations. The safety population contained patients who received at least one dose of medication. This study is registered with ClinicalTrials.gov, NCT02193776, and all patients have completed follow-up.

FINDINGS

Between Oct 24, 2014, and Dec 15, 2015, we enrolled 180 patients with drug-susceptible tuberculosis (59 were randomly assigned to B_loadPaZ, 60 to B₂₀₀PaZ, and 61 to HRZE) and 60 patients with rifampicin-resistant tuberculosis. 57 patients in the B_loadPaZ group, 56 in the B₂₀₀PaZ group, and 59 in the HRZE group were included in the primary analysis. B₂₀₀PaZ produced the highest daily percentage change in TTP (5·17% [95% Bayesian credibility interval 4·61-5·77]), followed by B_loadPaZ (4·87% [4·31-5·47]) and HRZE group (4·04% [3·67-4·42]). The bactericidal activity in B₂₀₀PaZ and B_loadPaZ groups versus that in the HRZE group was significantly different. Higher proportions of patients in the B_loadPaZ (six [10%] of 59) and B₂₀₀PaZ (five [8%] of 60) groups discontinued the study drug than in the HRZE group (two [3%] of 61) because of adverse events. Liver enzyme elevations were the most common grade 3 or 4 adverse events and resulted in the withdrawal of ten patients (five [8%] in the B_loadPaZ group, three [5%] in the B₂₀₀PaZ group, and two [3%] in the HRZE group). Serious treatment-related adverse events affected two (3%) patients in the B_loadPaZ group and one (2%) patient in the HRZE group. Seven (4%) patients with drug-susceptible tuberculosis died and four (7%) patients with rifampicin-resistant tuberculosis died. None of the deaths were considered to be related to treatment.

INTERPRETATION

B₂₀₀PaZ is a promising regimen to treat patients with drug-susceptible tuberculosis. The bactericidal activity of both these regimens suggests that they have the potential to shorten treatment, and the simplified dosing schedule of B₂₀₀PaZ could improve treatment adherence in the field. However, these findings must be investigated further in a phase 3 trial assessing treatment outcomes.

FUNDING

TB Alliance, UK Department for International Development, Bill & Melinda Gates Foundation, US Agency for International Development, Directorate General for International Cooperation of the Netherlands, Irish Aid, Australia Department of Foreign Affairs and Trade, and the Federal Ministry for Education and Research of Germany.

The role of regular liver function monitoring in antituberculosis drug-induced liver injury

BACKGROUND

Antituberculosis (TB) drug-induced liver injury (ATLI) is a common adverse effect of anti-TB drugs. Whether regular monitoring of liver function can ameliorate ATLI has been widely debated. The current study aimed to investigate the liver test monitoring status of patients receiving anti-TB treatment in Taiwan, as well as the impact of scheduled liver function monitoring on the risk of ATLI.

METHODS

Patients who received anti-TB treatment at our hospital between 2009 and 2017 were enrolled for retrospective analysis.

RESULTS

A total of 1062 patients were included, and of them 469 (44.2%) received regular liver function monitoring (good monitoring group). ATLI was recognized in 100 (9.4%) patients. The good monitoring group detected more ATLI cases early compared with the poor monitoring group (14.7% vs 5.2%, and 21.4 vs 61.6 days, p < 0.01), with a lower peak serum alanine aminotransferase (276.1 vs 507.1 IU/L, p = 0.05).

CONCLUSION

In the current study, less than half of all patients who received anti-TB drugs had their liver function monitored regularly. Scheduled monitoring of liver function could facilitate the early identification of more ATLI cases, thus leading to less liver injury. The implementation of periodic liver function monitoring tests in patients receiving anti-TB treatment should be re-emphasized and encouraged.

Tolerability of Isoniazid Preventive Therapy in an HIV-Infected Cohort of Paediatric and Adolescent Patients on Antiretroviral Therapy from a Resource-Limited Setting: A Retrospective Cohort Study

BACKGROUND

Treating patients with latent tuberculosis infection (LTBI) to prevent development of active disease is an essential strategy for eliminating TB. There are concerns regarding the use of isoniazid due to the potential for hepatotoxicity. This study was conducted to determine the incidence of adverse hepatic events after isoniazid preventive therapy (IPT) commencement in a cohort of HIV-infected paediatric and adolescent patients on antiretroviral therapy (ART).

METHODS

This was a retrospective records review, using data from HIV-infected paediatric and adolescent patients collected during routine clinical visits at Newlands Clinic, Harare, Zimbabwe. Patients included in the analysis had commenced IPT between January 2014 and June 2015 (inclusive) whilst receiving ART. A survival analysis was conducted for the period that participants were receiving IPT with end-points defined by grade 3 or grade 4 elevations in alanine aminotransferase (ALT) levels.

RESULTS

Data from 438 patients commenced on IPT were analysed; 202 (46.1%) of them were female. The median age at IPT commencement was 10 (IQR = 7-12) years. Twenty-eight patients developed grade 3 or 4 elevations in ALT. Concomitant use of nevirapine as part of an ART regimen was the only factor that showed a statistically significant association with ALT elevation [relative risk (RR): 2.7; confidence interval (CI): 1.2-6.3, p = 0.012] compared with those not receiving nevirapine. The incidence of grade 3 or 4 elevations in ALT was 31.5/100 person-years (CI 20.9-45.5).

CONCLUSION

The incidence of IPT-associated ALT elevations was high in this population. We recommend vigilant monitoring of liver enzymes for patients receiving IPT, especially in patients concomitantly receiving nevirapine.

Toxicity associated with tuberculosis chemotherapy in the REMoxTB study

BACKGROUND

The incidence and severity of tuberculosis chemotherapy toxicity is poorly characterised. We used data available from patients in the REMoxTB trial to provide an assessment of the risks associated with the standard regimen and two experimental regimens containing moxifloxacin.

METHODS

All grade 3 & 4 adverse events (AEs) and their relationship to treatment for patients who had taken at least one dose of therapy in the REMoxTB clinical trial were recorded. Univariable logistic regression was used to test the relationship of baseline characteristics to the incidence of grade 3 & 4 AEs and significant characteristics (p < 0.10) were incorporated into a multivariable model. The timing of AEs during therapy was analysed in standard therapy and the experimental arms. Logistic regression was used to investigate the relationship between AEs (total and related-only) and microbiological cure on treatment.

RESULTS

In the standard therapy arm 57 (8.9%) of 639 patients experienced ≥1 related AEs with 80 of the total 113 related events (70.8%) occurring in the intensive phase of treatment. Both four-month experimental arms ("isoniazid arm" with moxifloxacin substituted for ethambutol & "ethambutol arm" with moxifloxacin substituted for isoniazid) had a lower total of related grade 3 & 4 AEs than standard therapy (63 & 65 vs 113 AEs). Female gender (adjOR 1.97, 95% CI 0.91-1.83) and HIV-positive status (adjOR 3.33, 95% CI 1.55-7.14) were significantly associated with experiencing ≥1 related AE (p < 0.05) on standard therapy. The most common adverse events on standard therapy related to hepatobiliary, musculoskeletal and metabolic disorders. Patients who experienced ≥1 related AE were more likely to fail treatment or relapse (adjOR 3.11, 95% CI 1.59-6.10, p < 0.001).

CONCLUSIONS

Most AEs considered related to standard therapy occurred in the intensive phase of treatment with female patients and HIV-positive patients demonstrating a significantly higher risk of AEs during treatment. Almost a tenth of standard therapy patients had a significant side effect, whereas both experimental arms recorded a lower incidence of toxicity. That patients with one or more AE are more likely to fail treatment suggests that treatment outcomes could be improved by identifying such patients through targeted monitoring.