The World Health Organization (WHO) has updated its guideline for the treatment of drug-resistant tuberculosis (TB). The highlights of this update are a shorter 6-month all-oral anti-tubercular treatment for multidrug- and rifampicin-resistant TB (MDR/RR-TB) and a 9-month all-oral regimen for the treatment of MDR/RR-TB.¹ The complete updated guidelines are expected later this year.

According to the rapid communication released on Monday, the six-month “BPaLM regimen” can be used instead of the 9-month regimen or even longer regimen (>18 months) in patients, aged ≥15 years, with MDR/RR-TB who have not been exposed to bedaquiline, pretomanid and linezolid for more than a month. This regimen can be used without moxifloxacin (BPaL) in patients resistant to fluoroquinolones (those with pre-XDR-TB). The guideline strongly urges drug susceptibility testing to fluoroquinolones; at the same time, it cautions against delaying initiation of treatment.

The guideline has suggested a 9-month, all-oral regimen in place of longer treatment in patients with MDR/RR-TB, who have not been exposed to second-line treatment (including bedaquiline), with no resistance to fluoroquinolone and without extensive pulmonary TB disease or severe extrapulmonary TB. Linezolid 600mg for 2 months can be used in place of 4 months of ethionamide. Drug susceptibility tests are required to exclude fluoroquinolone resistance.

While the guideline recommends shorter treatment regimens, it advocates individualized longer regimens for patients who do not meet the required criteria or in cases of treatment failure with  shorter regimens or patients with XDR-TB. The priority group of medicines as recommended in the current WHO guidelines should be used.

The choice of treatment regimen should be based on clinical judgement paying heed to the preference/s of the patient. Treatment history, disease severity, site involved, results of the drug susceptibility test, adverse effects are other factors that must be considered in selecting the appropriate treatment regimen for the patient.

Reference

1. Rapid communication: key changes to the treatment of drug-resistant tuberculosis. Geneva: World Health Organization; 2022 (WHO/UCN/TB/2022.2)