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"I dream of a treatment for standard and MDR-TB that could be as short as several weeks. It's hard not to feel like we're fighting a losing battle with the tools we have today." Dr. Liesbet Ohler, MSF, Mathare near Nairobi, Kenya
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© Brendan Bannon |
Tuberculosis is curable but treatment is unacceptably long
For the most part, tuberculosis (TB) is a curable disease and is treated with a combination of antibiotic drugs that were developed over 40 years ago.
However, the treatment is long, stretching over six months at least. During this period, the patient must be encouraged to stick to the treatment until its completion, and not abandon the course as soon as the symptoms fade, which might be as soon as two weeks after the start of the treatment.
Interruptions of treatment before its completion can trigger the selection of mycobacteria that are resistant to the drugs in use, leading to the development of drug resistant forms of TB (DR-TB) more complex and lengthy to treat.
Resistant strains push us to the limits with current treatments
The emergence of drug-resistant strains presents much greater challenges for treatment. Since most of the drugs used in standard treatment don’t work, less effective, more toxic drugs that have been abandoned as first-line treatments have to be prescribed. The treatment therefore can take between 18 - 24 months and causes side effects similar to those experienced by people on cancer chemotherapy. One in five will die during treatment. For those patients who are also HIV positive, that number rises to 66%. Some of those treated will go on to develop highly resistant forms of TB (XDR-TB, extensively drug resistant TB) that have a high mortality rate – there are virtually no effective drugs to treat them - and can be transmitted to others.
The grim realities of treating MDR-TB
“We explain that the treatment is very long, with very violent side effects, and very serious constraints. Those who start this treatment have to know that they will neither be able to work nor sleep with their partner, nor play with their children for a long time whilst they are still infectious.... The intensive phase lasts a minimum of six months. The patient takes a cocktail of five drugs, which means a painful injection every day and a handful of pills every morning and every afternoon. Side effects are not only unpleasant, but are, in fact, often unbearable, and can actually be dangerous. It is a treatment that is as violent and toxic as cancer chemotherapy.” Dr. Cathy Hewison, MSF TB doctor in Abkhazia.
Necessary revolution in TB treatment still years down the road
In an effort to accelerate development of new tools for treating TB, MSF keeps current research activities into new treatments for TB under constant surveillance. After a long period of inactivity, there are now some forty new compounds under investigation.
However, this is not enough to answer the challenges we face in tackling the TB epidemic. It is unlikely that a useful new therapy will emerge out of the current pipeline, given that only about one compound in 20 successfully emerges from a drug discovery program. And several compounds are needed to offer effective combination therapy for TB. We need to see approximately 60 new lead compounds in the pipeline as soon as possible. Nothing less will avert the escalation of what is already a major public health catastrophe
Currently drug development efforts are focused on developing an entirely new regimen active against both drug sensitive and drug resistant TB. Although this is an important objective, it must not be pursued at the expense of patients' needs suffering now with drug-resistant TB for whom there are few effective medicines. An entirely new regimen of drugs will not be available for at least another decade.
At a meeting organized by MSF, international experts discussed the possibility of accelerating the development of new drugs for TB by trials in drug resistant patients. This strategy has proven successful for the development of new drugs for HIV/AIDS. Given the public health emergency we face with the spread of drug resistant TB, it is essential to explore the pathway of innovative MDR-TB trials.
Read more
MSF analysis of the current TB drugs pipeline 
PLoS paper on randomized clinical trials for DR TB
