"Sterilization of TB disease in

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1 11/1/1 "Sterilization of TB disease in mice " Jacques Grosset Pharmacodynamics of daily rifapentine and rifampin in mice Free rifam mycin Concentrati ion/mic 1 1 Rifapentine (1mg/kg) Free rifam mycin Concentrati ion/mic 1 1 Rifampin (1mg/kg) Center for TB Research Johns Hopkins University Time (hrs) Time (hrs) Rifapentine provides greater rifamycin exposure than does rifampin at the same given dose Rosenthal et al. PLoS Medicine, 7 Log 1 cfu in lungs Our goal Persisters INH + SM INH + RIF INH + RIF + PZA months Chemotherapy of TB: Activity of INH+SM, INH+RIF, or INH+RIF+PZA in mice (and in humans) against persisters Bactericidal activity of daily R 1 HZ & P 1 HZ 7 R 1 HZ P 1HZ Treatment duration (weeks) Conclusion:, To reach the culture ve state, it takes 1 weeks with P 1 HZ and 1 to weeks with R 1 HZ per Lung Log 1 CFU Rifapentine (P) Rifapentine (P) is a long lived rifamycin derivative developed for once weekly administration (Bock, ) Rifapentine offers potential for improved activity because of its superior PK/PD profile: Drug Half life (h) MIC 9 (μg/ml) C max /MIC 9 AUC /MIC 9 Rifampicin (1 mg/kg) Rifapentine (1 mg/kg) P may be safely administered more frequently and at higher doses than mg once a week Sterilizing efficacy of rifapentine (P) containing regimens Regimens Culture negative Relapse after treatment for at weeks at 1 weeks 1 weeks 1 weeks R 1 HZ /7 / (%) / (%) 1%! 1%! P 1 HZ /7 1/ (%) / (1%) /1 (% 13%) /1 (%) Questions: Does the culture negative state obtained in mice treated with PHZ correspond to a sterile state? Have we really killed all persisters? Absence of relapse may indicate the few remaining persisters are contained by specific immunity. Thus. 1

2 11/1/1 Data on the sterile state achieved by drug therapy McCune et al., 19: After culture conversion induced by INH + high dose PZA, the relapse rate was % without any intervention and 1% after cortisone 1 mg ( mg/kg) daily for days Grumbach et al., 197: After INH + RIF for 1 months, the relapse rate was % without any intervention but % after cortisone. mg ( mg/kg) daily for months Lung CFU counts after treatment for 1 month with P 1 HZ/1PH CFU/Lung Log 1 1 Weeks post treatment initiation : 3.93 :. p =. Basic study design Aim: Determine whether intensive treatment with daily (/7) P 1 HZ/PH leads to true sterilization Tests: Athymic nude (nu/nu) mice given PHZ/PH for 3,, 9, and 1 months and kept without treatment for 3 months to reveal sterile state Normal mice () treated as above but injected with cortisone (mg/kg, /7, for wks) upon treatment completion Normal mice () treated as above but without receiving cortisone upon treatment completion Controls: Exactly the same as above but treated with RHZ/RH Lung CFU counts after treatment for months with P 1 HZ/1PH CFU/Lung Log 1 1 Weeks post treatment initiation :.9 :.3 p =.17 Lung CFU counts on treatment initiation Lung CFU counts after treatment for 3 months with P 1 HZ/1PH All controls dead by Day All controls dead by Day CFU/Lung Log 1 CFU/Lung Log 1 1 Weeks post treatment initiation 1 Weeks post treatment initiation one day after infection :. :. on treatment initiation : 7. : 7.3 Conclusion: identical active growth of Mtb in normal and nude mice Conclusion: Response is significantly slower in nude mice than in normal mice but all mice were culture negative by 3 months

3 11/1/1 Relapse rate after treatment for 3 months with P 1 HZ/1PH Group of mice Cortisone Relapse rate 3 months later No Cortisone /1 (%) Relapse rate after treatment for /9/1 months with P 1 HZ/PH given d/week Group of mice Cortisone /1 Relapse rate 3 months later No Cortisone /1 /1 Conclusions: 1. After months of PHZ/PH given days a week, not a single nude mouse relapsed, indicating the spectacular sterilizing activity of rifapentine. The time to lung sterilization with PHZ/PH is therefore between 3 and months 3. A new experiment is in progress to determine the minimum time to sterilization of all mice with the P containing regimen Relapse rate after treatment for 3 months with P 1 HZ/1PH Group of mice Cortisone /1 (13%) * Relapse rate 3 months later No Cortisone /1 (%) *By error these mice received only. mg (mg/kg) daily cortisone instead of 1 mg (mg/kg) What about the control mice treated with RHZ/RH? In all mice, and, treated d/wk with R 1 HZ/RH, the cultures were still positive at the 3 month time point when they were all culture negative in mice treated with P 1 HZ/PH. This again emphasizes the potency of P over R. Let s see the details Relapse rate after treatment for 3 months with P 1 HZ/1PH Results during the first 3 months of treatment RHZ Group of mice Cortisone /1 (13%) Relapse rate 3 months later No Cortisone /1 (%) 11/1 (73%) Conclusions: 1. As seen previously, normal mice did not relapse spontaneously.only /1 normal mice given cortisone for 1 month relapsed (but..) 3.Only 11/1 nude mice relapsed! Log 1 CFU/Lung L - Log 1 CFU counts: one day after infection BALB/C:. :. 1 Weeks post treatment on treatment initiation BALB/C: 7. : 7.3 3

4 11/1/1 Rifampicin Conc. ( g/ml) Pyrazinamide Conc. ( g/ml) Rifampicin (1 mg/kg) 1 1 Time (hours) Pyrazinamide (1 mg/kg) 1 1 Time (hours) Drug (mg/kg) Isoniazid Conc. ( g/ml) 1 Isoniazid (1 mg/kg) Time (hours) Mice C max AUC - (mg.h/l) Humans C max AUC - (mg.h/l) RIF 1 1. ± INH rapid - - Cmax. ±. AUC. R1-1. ± 3.3 ± slow H1.7 ± INH 1 ± PZA -3 - Z ± ±.9 ± 11 PZA ± What have we done? A new experiment in which nu/nu and Balb/C mice were treated for 3 months with: versus 7 days a week RHZ/RH versus RHZE*/RH *ethambutol 1mg/kg Results after months of treatment in nude mice treated with RHZ/RH, RHZ times weekly Log 1 CFU/Lung INH-R mutants * INH-R** RIF-S 1 1 Weeks post treatment * Between 1% to % CFU resistant to. µg/ml of INH ** For all mice, ~ 1% CFU resistant to. & 1 µg/ml of INH 1. Is 7 day/wk treatment able to prevent selection of INH resistant mutants? (RHZ/RH days a week versus 7 days a week in Balb/C and Nu/nu mice) Strain of mice Rhythm of treatment D 13 D M1 M M3 Resist to INH Balb/C untreated Dead by D / /1 7/7.3.. /1 Nu/nu Untreated. 7.3 Dead by D / /1 7/ /1 Conclusions: 1. 7/7 is more active than /7 treatment but. Treatment with RHZ/RH given 7/7 does not protect better against INH resistance than /7 in nu/nu mice Results after months (3wks) of treatment in mice treated with RHZ/RH, times weekly. Is the addition of ethambutol (E) able to prevent the selection of INH resistant mutants? (RHZE/RH 7/7 versus /7) ** * Strain of mice Rhythm of treatment D 13 D M1 M M3 Resist to INH Balb/C untreated Dead by D / /1 7/ /1 Nu/nu Untreated. 7.3 Dead by D / /1 7/ /1 *All INH R and RIF S. But mice [ at wk 3 & at wk 3 out of 7 (1.%)] were culture negative, indicating that the treatment was active when there was no selection of INH R mutants in mice. ** Mock multiplication in untreated nude mice Conclusion: The addition of E protected against selection of INH resistant mutants when RHZE/RH was given /7 or 7/7

5 11/1/1 3. Is 7 days a week more potent than days a week? (RHZE/RH d/wk versus 7d/wk in Balb/C and Nu/nu mice) Strain of mice Rhythm of treatment D 13 D M1 M M3 Resist to H Balb/C untreated Dead by D / /1 7/ /1 Nu/nu Untreated. 7.3 Dead by D / /1 7/ /1 Conclusions: 1. In both mouse strains 7/7 is. to 1. log 1 more bactericidal than /7. The response to /7 or 7/7 is 1 to log 1 better in Balb/C than in nu/nu Conclusion: 1. the facts P 1 HZ/PH given /7 sterilizes TB disease in nude mice within 3 to months Nu/nu mice treated with daily RHZ/RH selected INH resistant mutants and not RIF resistant mutants The addition of EMB (E) during the -month initial phase prevented the selection of INH resistant mutants 7/7 treatment is on average 1 to 1. log 1 more bactericidal than /7, both in nu/nu and Balb/C mice The bactericidal activity of RHZE/RH in nu/nu mice is reduced by 1 to log 1 compared to Balb/C Log 1 CFU co ounts in Lungs 9 Treatment initiation RHZE RH Balb/C-Untreated Balb/C-RHZE /7 Balb/C-RHZE 7/7 Nu-Untreated Nu-RHZE /7 Nu-RHZE 7/7 Weeks Conclusion:. Speculations One can predict a spectacular efficacy of the P 1 HZE/PH treatment in humans (TBTC study 9) In immune-deficient hosts, bacilli are not contained by the host immunity and can re-grow as soon as they are no more under the control of antibiotics: - Should immune-deficient patients with TB be preferably treated daily and seven days a week (7/7)? The inability of daily R (a sterilizing but poorly bactericidal drug) to prevent the selection of H (a potent bactericidal drug) resistant mutants in the absence of a specific immune response is amazing. Perhaps should we increase dose/rhythm of R? The ability of Ethambutol (a bacteriostatic drug), in combination with RHZ, to prevent the selection of H resistant mutants in nude mice is amazing. Does ethambutol substitute for the immune containment? 1 Lung CFU counts in Balb/C (B) and nude (Nu) mice treated /7 (---) vs 7/7 ( ) with RHZE. Is the addition of ethambutol increasing the bacteridal actity? Strain of mice Balb/C Drug Log 1 lung CHU at following time points regimens D M1 M M3 untreated 7.7 /7 ZHZ/RH /7 RHZE/RH Acknowledgements We acknowledge the support of all TB center members and of NIAID (Contract # N1-AI-7) We thank Sanofi Aventis for providing rifapentine and I thank you for your attention 7/7 RHZ/RH.3.. 7/7 RHZE/RH Conclusion: The addition of ethambutol does not increase bactericidal activity

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7 Tuberculosis and HIV Co-infection November 3, 1 Timothy R. Sterling, M.D. Vanderbilt University School of Medicine Smear-negative TB in HIV + Persons Atypical CXR presentation Risk is increased in HIV + persons Proportion of TB in HIV + persons that is smear-negative pulmonary: -1% 1 institution-based studies May be an under-estimate Risk of death increased Compared to HIV-negative smear-negative TB patients immunosuppression Compared to HIV-positive smear + TB patients delay in diagnosis Getahun H. Lancet 7;39:-9. Issues in TB/HIV Clinical Presentation of TB in HIV + Persons Sub-clinical TB, atypical presentation Immune reconstitution Treatment of TB/HIV Optimal duration of therapy; relapse risk Development of drug-resistant TB Acquired rifamycin resistance TB drug levels in HIV+ patients Drug-drug interactions Algorithm for TB Screening in HIV+ Persons 1,7 HIV+ persons in Cambodia, Thailand, and Vietnam TB diagnosed in 7 (1%) Presence of cough for > -3 weeks during the preceding weeks: -33% sensitive -% specific Presence of at least one (cough any duration, fever any duration, night sweats for > 3 weeks in preceding wks) 93% sensitive 3% specific 97% negative predictive value Cain KP. N Engl J Med 1;3:77-1. Diagnosis of TB in HIV+ Persons 1,199 patients who reported > 1 of these symptoms Tanzania 1/93 (1%) of HIV+ subjects (CD > ) screened for TB vaccine trial had active TB 1 (71%): clinical TB Symptoms or abnormal CXR (9%): sub-clinical TB +AFB smear/cx but no symptoms and normal CXR more cases subsequently identified» Of the 1, 7 identified only by + culture Mtei L. Clin Infect Dis ;:1-7 South Africa 17 HIV+ persons evaluated with AFB smear and culture 7 already on TB Rx previously undiagnosed smear + TB, smear-neg/culture + TB % had previously undiagnosed TB. Symptom screen not useful Wood R. AJRCCM 7;17:7-93 Supports use of CXR, sputum culture to rule out TB Generally not done in developing world /1199 = % /1199 = % 13/1199 = 1% Cain KP. N Engl J Med 1;3:77-1. Of 9 patients without any of the 3 screening symptoms, 1 (3%) had TB 1

8 Case Presentation Development of TB after HAART Initiation Schematic representation of the different forms of TB-associated IRIS and ART-associated TB y.o. HIV+ male with diarrhea, fevers, 3 lb weight loss. No cough or SOB. CXR negative. C CD = 3 3 HIV-1 RNA: 9, 9, TDF/FTC/lopinavir/ritonavir initiated days later: presents with cough, fever. CXR: RUL cavitary infiltrate Culture-confirmed pulmonary TB Meintjes G et al for the International Network for the Study of HIVassociated IRIS. Lancet Infect Dis ;:1-3. Manabe Y. J Infect Dis. 9 Feb 1;199(3):37-. Immune Reconstitution Inflammatory Syndrome Among Persons Known to Have TB Clinical Manifestations Prior to HAART days after starting HAART Constitutional: fever, weight loss Pulmonary: cough, increased infiltrates Extrapulmonary: Lymphatic: increased cervical, intra-thoracic, intraabdominal adenopathy Serositis: pleural, pericardial effusions CNS: expanding tuberculomas Other: soft tissue, bone abscesses, skin, +PPD Smear-positive, culture-negative Manabe Y. J Infect Dis. 9 Feb 1;199(3):37-. Schematic representation of the different forms of TB-associated IRIS and ART-associated TB Previously undiagnosed prevalent TB Newly-acquired TB Meintjes G. Lancet Infect Dis. Lawn SD. AJRCCM. Manabe Y. J Infect Dis 9. Progression of sub-clinical TB present before ART (reactivation) A sub-set have IRIS Meintjes G. Lancet Infect Dis ;:1-3.

9 Effect of HAART on TB risk Overall, immune reconstitution due to HAART decreases, not increases, TB risk Unmasking of sub-clinical TB due to immune reconstitution on HAART can occur Implications for ART implementation in settings with high TB incidence Incomplete long-term immune restoration TB risk higher than in HIV-seronegative persons Lawn SD. AIDS ;19: Lawn SD AJRCCM ;177:-. Manabe Y JID 9. Treatment of TB for Months HIV-seropositive vs. HIV-seronegative Location Relapse HIV+ Relapse HIV- Reference Zaire 9%.3% Perriens NEJM 199 Cote d Ivoire 3% 3% Kassim AIDS 199 Haiti.%.7% Chaisson AJRCCM 199 U.S. 3.9% El-Sadr CID 199 South Africa % % Connolly AIDS 1999 U.S..% 3% Sterling AIDS 1999 Recurrent TB After Treatment Completion Relapse vs. Reinfection Relapse: disease with the same M. tb strain as the first episode Related to treatment duration, effectiveness Reinfection: disease with new strain of M. tb Related to TB prevalence in area Optimal Duration of TB Treatment Regardless of HIV status Site of Disease Pulmonary Bone/joint CNS/meningeal Other extrpulmonary Duration months* -9 months 9-1 months months *Extend to 9 months if cavitary and culture + at months American Thoracic Society, Centers for Disease Control, IDSA. Treatment of Tuberculosis. AJRCCM 3;17:3- Recurrent TB Relapse vs. Reinfection In TB-endemic areas, recurrent TB after completion of therapy more likely due to exogenous reinfection than relapse van Rie, et al. N Engl J Med. 1999;31:117. Narayanan S. J Infect Dis. 1 Mar 1;1(): HIV+ TB patients have higher risk of recurrent TB than HIV-negative TB patients, but this is due to reinfection, not relapse Sonnenberg P, et al. Lancet 1;3:17 Glynn JR. J Infect Dis. 1 Mar 1;1():7-11.Crampin AC. AIDS 1;:17. Treatment of TB in HIV+ Persons Relapse Rates months Relapse rate = % (range: 3 9%) Perriens NEJM 199 El-Sadr CID 1 Sterling AIDS 1999 Korenromp CID 3 Fitzgerald Lancet Nettles CID Nahid AJRCCM 7 9 months Relapse rate = % (range 1 3%) Pulido Arch Intern Med 1997 Driver CID 1 3

10 Treatment of TB/HIV Systematic Review and Meta-analysis randomized trials, 1 cohort studies Trend toward higher relapse rate if: rifamycins i used for months vs. > months antiretroviral therapy not used Thrice-weekly therapy in initial phase associated with higher failure and relapse rates than daily therapy Pharmacokinetics of INH + Rifabutin Acquired Rifamycin Resistance Included 1/13 Study 3 patients;7/ with ARR ARR No ARR P Rifabutin AUC 3.3 g*ml/hr. g*ml/hr. adjusted for CD 3... Isoniazid AUC... adjusted-rbt AUC. Khan FA. Clin Infect Dis 1;: Weiner M. Clin Infect Dis ;:11-91 Outcome vs. 9 Months India; Thrice-weekly TB Rx; No ART months N=17 9 months N=1 P-value Favorable 3% 7% NS response Bacteriologic 1% 7% <. recurrence All recurrence 19% 13% NS Death-3 months 3% 3% NS Median CD: 1 Median HIV-1 RNA: 1, copies/ml All 19 patients with Rx failure: acquired rifamycin resistance No difference in ARR by treatment arm Swaminathan S. AJRCCM 1;11:73-1. Rifabutin Isoniazid Weiner M. Clin Infect Dis ;:11-91 Acquired Rifamycin Resistance TB Trials Consortium Study 3 Isoniazid + rifabutin twice-weekly in continuation phase 19 patients enrolled 3 treatment failures + relapses; 9/19 =.3% /9 (9%) acquired rifamycin resistance Risk factors for ARR: ARR No ARR P n= n=11 Median CD 99.1 ART in 1 st mos. of TB Rx 1% %. Recommendations for Treatment of TB in HIV-Infected Patients TB/HIV patients with CD < 1 should not receive once- or twice- weekly therapy Daily therapy during induction Daily or thrice-weekly therapy during continuation Burman W. Am J Respir Crit Care Med ;173:3-. MMWR ;1:1-

11 Prevalence of Low Drug Levels During TB Treatment TB patients in Botswana DOT HIV-infected and -uninfected Low TB drug levels common Drug % with low C max INH 37 RIF EMB 39 PZA Chideya S. Clin Infect Dis 9;:1-9. Chideya S. Clin Infect Dis 9;:1-9. Treatment of TB/HIV Possible Uses of Rifampin ( mg) RIF + efavirenz (consider mg) RIF + ritonavir mg bid RIF + lopinavir ( mg) + ritonavir ( mg) Concern re: hepatotoxicity in adults (OK if < 3 years old) Above regimens must also include NRTIs Do not use rifampin with other PIs, even if the PI is given with ritonavir Chideya S. Clin Infect Dis 9;:1-9. MMWR ;9:1-9. CID ;3:-9. Updated May 1, From CLIN INFECT DIS (1): by the Infectious Diseases Society of America. All rights reserved. For permission to reuse, contact journalpermissions@press.uchicago.edu. Rifampin-Efavirenz Rifampin efavirenz AUC by % Consider efavirenz to mg qd CDC, NIH. MMWR ;3:RR-1 India: HIV+ patients with CD < All:EFV mg;1 (TB) also rifampin mg Same clinical, immunologic response Patel A et al. JAIDS ;37:11-9 Thailand: TB/HIV patients; mean weight kg EFV mg vs. mg: similar EFV levels and outcomes Manosuthi W. AIDS ;19:11-. South Africa: 19 TB/HIV EFV mg + rifampin mg EFV levels varied but good clinical outcomes Friedland G et al. JAC ;:199-3.

12 Rifampin-Nevirapine Rifampin lowers nevirapine levels by 37-% 3 small studies demonstrated favorable clinical and virologic response Ribera E JAIDS 1. Olivia J AIDS 3. Manosuthi CID. In a small study comparing mg NVP and mg EFV (both with rifampin), efficacy was similar but adverse events more common with NVP Manosuthi W. HIV Med ;9:9-9. At week 1, NVP levels more likely to be low than with EFV (1% vs. 3%; P=.) Manosuthi W. CID 9;:17-9. No clinical, pk, safety studies assessing increased nevirapine dose with rifampin Consider NVP + RIF when cannot use EFV, rifabutin not available, and close clinical and virologic monitoring can be performed Treatment of HIV-related TB Summary The clinical manifestations of TB in HIV-infected persons differ compared to HIV-uninfected persons Atypical or normal CXR Fewer symptoms Particularly with low CD; symptoms, CXR can worsen on ART Optimal treatment duration months enough? Daily dosing of TB therapy, particularly in first months Poor treatment outcomes associated with low PZA levels Acquired rifamycin resistance associated with low rifamycin levels, and perhaps low INH levels Advanced HIV, intermittent TB dosing also risk factors Acquired INH resistance not reported Failure to Suppress Viral Load in Patients With Concurrent TB at the Start of Antiretroviral Therapy vs Those Without Concurrent TB Boulle, A. et al. JAMA ;3:3-39. Copyright restrictions may apply. Treatment of TB/HIV New Agents Etravirine Rifampin etravirine do not give with rifampin Can give with rifabutin, but not together with DRV/r, SQV/r CCR inhibitors (maraviroc) Rifampin maraviroc C min by 7% in maraviroc dose to mg bid may help, but no clinical experience Interactions with rifabutin not studied; modest effect likely Integrase inhibitors (raltegravir) Rifampin raltegravir Cmax, AUC, trough levels by -71% Do not co-administer Can give RBT 3 mg qd with raltegravir mg bid Sterling TR. Clin Infect Dis 1;:S3-S3.