The treatment of drug resistant TB has always been more difficult than the treatment of drug susceptible TB. It has required the use of reserve or second line drugs that are more costly and cause the patient more side effects. Also the drugs must be taken for up to two years.
WHO Consolidated Guidelines
In 2019 the World Health Organisation published Consolidated Guidelines on the treatment of drug resistant TB.1WHO consolidated guidelines on drug-resistant tuberculosis treatment, WHO, 2019, https://www.who.int/tb/publications/2019/consolidated-guidelines-drug-resistant-TB-treatment/en/ It is also planned that there is going to be a major update of these guidelines in 2020. It is said that the updated consolidated guidelines have substantially changed the approach to the treatment of MDR/XDR-TB.2Emanuele Pontali et al, "Regimens to treat multidrug-resistant tuberculosis: past, present and future perspectives", 2019, European Respiratory review, https://err.ersjournals.com/content/28/152/190035#ref-32
The consolidated guidelines include a comprehensive set of WHO recommendations based on, and replacing, eight previous WHO guidelines documents. The consolidated guidelines include:
- policy recommendations on treatment regimens for isoniazid resistant TB and multi drug and rifampicin resistant TB (MDR/RR-TB), including longer and shorter regimens,
- culture monitoring of patients on treatment,
- the timing of antiretroviral therapy in MDR/RR-TB patients infected with HIV,
- the use of surgery for patients receiving MDR-TB treatment, and
- optimal models of patient support and care.
It needs to be emphasized that treatment for drug resistant TB should only be provided under the supervision of an experienced doctor. This includes the choice of a shorter or longer regimen, and also whether injectable drugs are used.
The Need for Shorter Regimens
The length of treatment regimens for drug resistant TB had continued to be a difficulty. The following is the type of problem that patients taking the drugs were faced with.
“These drugs are so horrible to eat every day. After nearly a year and a half, I thought it was just too much; I couldn’t keep taking all those pills. I thought it would be OK if I stopped taking them. But they told me if I didn’t keep going I might get sick again .... So I kept going with the pills and now I am cured. It was such a long time.”
Drug resistant TB patient 3Keshavjee, S., Farmer, P.E. “Time to put boots on the ground: making universal access to MDR-TB treatment a reality”, Int J Tuberc Lung Dis, 14(10), October 2010, 1222-1225
Shorter TB regimens
And so the search began for shorter regimens for the treatment of drug resistant TB. It was believed that shorter regimens would be easier to take.
This led to the development of the Bangladesh regimen which appeared to have higher TB cure rates and the drugs only needed to be taken for eight or nine months. There were also other shorter regimens being tested. The World Health Organisation (WHO) reaffirmed its recommendations on the use of shorter regimens following release of the STREAM trial data.
Injectable drugs for the treatment of drug resistant TB
Even when patients could take the Bangladesh regimen it still did not solve all the problems. It still required patients to have injections as part of their TB treatment. For some patients these could be extremely painful and difficult as Zolelwa Sifumba explains below.
“The injection was like nothing I’d ever felt before. It burns from the second it starts - it is quite a thick serum so you can’t inject it in fast. It takes some time. The pain went down my legs and up to my back. It is so painful. No injection should be that painful. It is intense pain that never stops.”
The pain lasts after the patient walks out of the doctor’s room.
“It is painful to get up. It is painful to go shower. It is painful to eat. It is painful to go to school. Everything is so difficult all day. And the next day when you go for your injection, you’re still in pain from the last injection”4“Frightening injection sends never-ending pain throughout your body”,
Not every patient suffered in this way, but the fact that some did, meant that the search continued for both shorter and longer TB treatments for the treatment of drug resistant TB, that didn't involve any type of injectable drug. There was also a need to exclude the drug Streptomycin whenever possible, due to its side effect of hearing loss.
WHO Recommendations for injectable drugs
According to the 2019 consolidated guidelines from WHO, fully oral regimens should be prioritized and should become the preferred option for most patients. Injectable agents should no longer be among the priority medicines to consider when designing longer MDR-TB regimens.
This is excellent news for patients.
This page was last updated in April 2020.
Author Annabel Kanabus
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