Daily vs Intermittent Antituberculosis Therapy for Pulmonary Tuberculosis in Patients With HIV: A Randomized Clinical Trial

• Published in: JAMA internal medicine Vol. 178; no. 4; p. 485
• Main Authors: Gopalan, Narendran, Santhanakrishnan, Ramesh Kumar, Palaniappan, Alangudi Natarajan, Menon, Pradeep Aravindan, Lakshman, Sekar, Chandrasekaran, Padmapriyadarsini, Sivaramakrishnan, Gomathi Narayan, Reddy, Devarajulu, Kannabiran, Bhavani Perumal, Agiboth, Hemanth Kumar Kupparam, Krishnamoorthy, Vijay, Rathinam, Sridhar, Chockalingam, Chandrasekar, Manoharan, Tamizhselvan, Ayyamperumal, MahilMaran, Jayanthi, Nalini, Satagopan, Kumar, Narayanan, Ravichandran, Krishnaraja, Raja, Sathiyavelu, Sekar, Kesavamurthy, Bhanu, Suresh, Chandra, Selvachitiram, Murugesan, Arasan, Gunasundari, Susaimuthu, Stella, Rathinam, Prabhakaran, Angamuthu, Prabhakar, Jayabal, Lavanya, Murali, Lakshmi, Ramachandran, Ranjani, Tripathy, Srikanth Prasad, Swaminathan, Soumya
• Format: Journal Article
• Language: English
• Published: United States 01.04.2018
• Subjects: Adult; Anti-HIV Agents - therapeutic use; Antitubercular Agents - administration & dosage; CD4 Lymphocyte Count; Directly Observed Therapy; Drug Administration Schedule; Ethambutol - administration & dosage; Female; HIV Infections - complications; HIV Infections - drug therapy; Humans; Immune Reconstitution Inflammatory Syndrome - chemically induced; Isoniazid - administration & dosage; Male; Middle Aged; Patient Dropouts; Proportional Hazards Models; Rifampin - administration & dosage; Streptomycin - administration & dosage; Treatment Failure; Treatment Outcome; Tuberculosis, Multidrug-Resistant; Tuberculosis, Pulmonary - complications; Tuberculosis, Pulmonary - drug therapy; Viral Load
• ISSN: 2168-6114
• DOI: 10.1001/jamainternmed.2018.0141

The benefit of daily over thrice-weekly antituberculosis therapy among HIV-positive patients with pulmonary tuberculosis (TB) who are receiving antiretroviral therapy remains unproven. To compare the efficacy and safety of daily, part-daily, and intermittent antituberculosis therapy regimens in the treatment of HIV-associated pulmonary TB. This open-label, randomized clinical trial was conducted by the National Institute for Research in Tuberculosis, south India. Adults infected with HIV with newly diagnosed, culture-positive, pulmonary TB were enrolled between September 14, 2009, and January 18, 2016. Patients were randomized to daily, part-daily, and intermittent antituberculosis therapy regimens, stratified by baseline CD4 lymphocyte count and sputum smear grade. Antiretroviral therapy was initiated as per national guidelines. Clinical and sputum microbiological examinations of patients were performed monthly until 18 months after randomization. Adverse events were recorded using standard criteria. The primary outcome was favorable response, defined as treatment completion with all available sputum cultures negative for Mycobacterium tuberculosis during the last 2 months of treatment. Unfavorable responses included treatment failures, dropouts, deaths, and toxic effects among regimens. Of 331 patients (251 [76%] male; mean [SD] age, 39 [9] years; mean [SD] HIV viral load, 4.9 [1.2] log10 copies/mL; and median [interquartile range] CD4 lymphocyte count, 138 [69-248] cells/μL), favorable responses were experienced by 91% (89 of 98), 80% (77 of 96), and 77% (75 of 98) in the daily, part-daily, and intermittent regimens, respectively. With the difference in outcome between daily and intermittent regimens crossing the O'Brien-Fleming group sequential boundaries and acquired rifampicin resistance emergence (n = 4) confined to the intermittent group, the data safety monitoring committee halted the study. A total of 18 patients died and 18 patients dropped out during the treatment period in the 3 regimens. Six, 4, and 6 patients in the daily, part-daily, and intermittent regimens, respectively, had TB recurrence. Among HIV-positive patients with pulmonary TB receiving antiretroviral therapy, a daily anti-TB regimen proved superior to a thrice-weekly regimen in terms of efficacy and emergence of rifampicin resistance. clinicaltrials.gov Identifier: NCT00933790.