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Replacement Sequence in the H Mono/Poly DR-TB
Learning ObjectivesReplacement Sequence in the H Mono/Poly DR-TB and Shorter Oral Bdq-containing MDR/RR-TB Regimens
Different conditions may demand the replacement of Isoniazid (H) mono/ poly Drug-resistant TB (DR-TB) and shorter oral Bedaquiline (Bdq)-containing Multidrug-resistant (MDR)/ Rifampicin-resistant (RR) -TB regimens.
Replacement Sequence of Drugs in H Mono/ Poly DR-TB Regimen
Drugs of the H mono/ poly DR-TB regimen will be replaced in case of:
- Additional resistance to one of the drugs in the regimen
- Intolerance to any of the drug/s used in the regimen
- Unavailability of one of the drug
- Contraindication of the component drugs of the regimen
In such situations, modification of H mono/ poly DR-TB regimen may be done using the sequence of using replacement drugs as delineated in the table below.
| SITUATION | SEQUENCE OF USING REPLACEMENT DRUGS |
|---|---|
| If Levofloxacin (Lfx) can’t be used |
Replace with High dose Moxifloxacin (Mfxh) if second line-line probe assay pattern suggests. Do liquid culture drug susceptibility testing for detection of resistance to Mfxh, Pyrazinamide (Z), Linezolid (Lzd) and Clofazimine (Cfz) |
| If Mfxh or Z can’t be used | Replace with Lzd. If Lzd also cannot be given, replace it with Cfz* + Cycloserine (Cs). |
| If both Mfxh and Z can’t be used | Add 2 drugs of the 3 – Lzd, Cfz*, Cs in order of preference based on resistance, tolerability & availability. |
| If Rifampicin (R)-resistance exists | Switch to an appropriate shorter or longer regimen. |
| *whenever Drug Susceptibility Test (DST) is available. |
- In the first three situations above, treatment will continue for a total duration of 9 months.
- Treatment duration of H mono/ poly DR-TB regimen can be longer in extensive pulmonary TB diseases up to 9 months.
- The use of new drugs is not yet recommended in the treatment of H mono/ poly DR-TB cases due to lack of evidence.
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Replacement Sequence of Drugs in Shorter Oral Bdq-containing MDR/RR-TB Regimen
- If there is a need for stopping/ replacing any drug in the shorter oral Bedaquiline-containing multi-drug resistant (MDR)/rifampicin-resistant tuberculosis (RR-TB) regimen then this regimen needs to be stopped.
- Evaluate the patient to switch to a longer oral Multi (M)/ Extensively Drug-resistant TB (XDR-TB) regimen.
- Replacement/ stopping any of the drugs in the regimen is not recommended.
Resources
- Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.
- WHO Consolidated Guidelines on Tuberculosis: Module 4 - Treatment: Drug-resistant TB Treatment 2020.
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