10.1 Introduction

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    When selecting or building a treatment regimen for multidrug-resistant tuberculosis (MDR-TB) and rifampicin-resistant tuberculosis (RR-TB), the following should be considered:

    10.1.1 Short treatment regimens and long treatment regimens

    Short treatment regimens (STR) are standard regimens, i.e. composition and duration are predefined for a group of patients. 

    Long treatment regimens (LTR) are individualized regimens, i.e. composition and duration are individually tailored. 

    Patients should receive an STR except if they do not meet the eligibility criteria for STRs, or do not tolerate STRs. In such cases, patients require an LTR.  

    It may be necessary to switch from an STR to another STR or an LTR, based on the latest drug-susceptibility test (DST) results and/or clinical evolution during treatment course (e.g. drug intolerance, persistence of a positive culture). 

    10.1.2 Likely effective drugs

    Treatment is based on a combination of "likely effective" TB drugs.

     

    Table 10.1 – Definition of likely effective drugs (adapted from WHO[1]Citation 1.World Health Organization. Companion handbook to the WHO guidelines for the programmatic management of drug-resistant tuberculosis. Geneva. 2014.
    https://www.ncbi.nlm.nih.gov/books/NBK247420/pdf/Bookshelf_NBK247420.pdf    )

     

    DST

    Definition of a likely effective TB drug

    Available and reliable

    DST indicates susceptibility to the drug.

    Unavailable, unreliable, or result pending

    The following criteria should be met:

    • No resistance detected by DST to a drug with cross-resistance.
    • No resistance to the drug or to a drug with a cross-resistance to it detected by DST in the presumed source case.
    • No previous exposure (> 1 month) to the drug or to a drug with a cross-resistance.
    • The drug has not been widely used in the treatment of TB or drug resistance surveys indicate that drug resistance is rare in the area the patient comes from.

     

    When the criteria of a likely effective drug are not met:

    • If the strain of the patient (or the presumed source case) is resistant to clofazimine, bedaquiline can be used but not counted as a likely effective drug until DST demonstrates susceptibility to bedaquiline. The same applies to all drugs with known or potential cross-resistance (e.g. delamanid/pretomanid). For more information on drug resistance and cross-resistance, see Chapter 8.
    • If a drug has been widely used and there is no reliable DST for this drug (e.g. ethambutol, cycloserine, para-aminosalicylate sodium): it can be used but never counted as a likely effective drug.
    • If a drug has been widely used and there is a reliable DST for this drug (e.g. pyrazinamide): it can be used but not counted as a likely effective drug until DST demonstrates susceptibility.

    10.1.3 Other considerations

    The following should also be considered when choosing or building a treatment regimen:

    • Site of the disease

    • Patients’ characteristics: age, comorbidities that can result in increased drug toxicity, pregnancy and breastfeeding (Section 10.4.1 and Appendix 11), drug tolerance
    • Absolute contra-indications to any drug included in a regimen
    • Interactions and overlapping toxicities between TB drugs or other drugs the patient may take (see Appendix 10 for individual drugs and Appendix 19 for co-administration of TB drugs and antiretrovirals)
    • Patient's preferences

     

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