75. Antituberculotic drugs. Anti-leprosy drugs

From greek.doctor

Antituberculotic drugs

Treating mycobacteria is a challenge for the following reasons:

  • The mycobacterial cell wall is thick and less permeable for antibiotics, and it expresses several efflux transporters
  • Mycobacteria multiply slowly
  • Many mycobacteria are genetically resistant to many antibiotics

For these reasons there are many drugs which are available for treating TB, so that we have multiple options in case of resistance.

The first-line agents in treating TB are:

  • Isoniazid
  • Rifampin/rifampicin
  • Pyrazinamide
  • Ethambutol

The standard first-line treatment of TB is 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of just isoniazid and rifampin.

There are several second-line agents as well, used in case of resistance to the first-line agents:

  • Streptomycin
  • PAS (para-aminosalicylic acid)
  • Ethionamide
  • Cycloserine
  • Fluoroquinolones
  • Bedaquiline
  • Delamanid

A person with TB should never receive monotherapy to prevent resistance. The patient should be observed taking the drugs to ensure correct treatment.

Adverse effects

Many of the antituberculotic agents can cause hepatotoxicity, in fact three of the four first-line agents do. If significant hepatotoxicity is detected the therapy should be suspended and second-line agents should be used.

Pyrazinamide and ethambutol also cause hyperuricaemia, which can be a problem for people with or at risk for gout.

Isoniazid

Indications

  • M. tuberculosis
  • M. kansasii

Mechanism of action

Isoniazid inhibits the synthesis of mycolic acid, an important component of the mycobacterial cell wall. It does this by inhibiting the FAS 2-system.

It is a prodrug which is activated by mycobacterial catalase-peroxidase. It is bactericidal against dividing mycobacteria and bacteriostatic against resting mycobacteria.

Resistance

1 in 1 000 000 mycobacteria are resistant to isoniazid. A granuloma usually contains billions of bacteria, so isoniazid monotherapy would just select out the resistant bacteria and create a resistant infection.

Decreased expression of catalase-peroxidase can me a mechanism of resistance.

Pharmacokinetics

Isoniazid is orally absorbed and well distributed, even into the CNS and the intracellular space.

It is eliminated mainly by acetylation in the liver with small amounts being excreted unchanged by the kidneys. The half-life depends on the patient. In rapid acetylators the half-life is 1 hour, in slow acetylators it’s 3 – 5 hours. In slow acetylators the proportion of isoniazid which is excreted unchanged is increased.

Interactions

Isoniazid is a CYP1A2 and CYP2C9 inhibitor. It can interact with many drugs, like propranolol, amitriptyline, warfarin, phenytoin and ibuprofen.

Side effects

Three major side effects can occur in isoniazid treatment:

  • Hypersensitivity reactions
    • Rarely SLE
  • Neurotoxicity
    • Peripheral neuropathy
  • Hepatotoxicity
    • Liver enzyme increase (15%)
    • Hepatitis (1%)

All three side effects are more common in slow acetylators. The latter two side effects are dose dependent.

Neurotoxicity is mediated by vitamin B6 deficiency, which occurs during isoniazid treatment. Both the neurotoxicity and hepatotoxicity can be prevented by supplementing B6.

Pyrazinamide

Indications

The only bacterium sensitive to pyrazinamide is m. tuberculosis. Pyrazinamide is part of the first-line treatment for TB.

Mechanism of action

Pyrazinamide inhibits the synthesis of mycolic acid, just like isoniazid. However, while isoniazid inhibits FAS2, pyrazinamide inhibits FAS1, the step before FAS2 in mycolic acid synthesis.

Pyrazinamide is a prodrug which is activated inside mycobacteria by the enzyme pyrazinamidase.

This drug has pH-dependent activity, which makes it ineffective at physiological pH, but bactericidal at acidic pH, like in the lysosomes of macrophages and in necrotic tuberculotic cavities.

Pharmacokinetics

It is orally absorbed and well distributed. It is eliminated by the kidney.

Side effects

  • Hepatotoxicity
  • Hyperuricaemia

Rifamycins

The most important rifamycins are rifampin/rifampicin and rifabutin. Rifampin is part of the first-line therapy for TB. They are covered in topic 69.

Ethambutol

Indications

M. tuberculosis and m. avium-intracellulare are sensitive to ethambutol. This drug is part of the first-line treatment for TB.

Mechanism of action

Ethambutol inhibits the synthesis of arabinogalactan, a component of the mycobacterial cell wall.

Pharmacokinetics

Ethambutol is orally absorbed and well distributed. It’s mostly excreted by the kidney in unchanged form.

Side effects

  • Optic neuritis
    • Diminished visual acuity
    • Blindness
  • Hyperuricaemia

PAS

PAS (para-aminosalicylic acid) is not the same as the PAS-stain in histology.

Indications

Only m. tuberculosis is sensitive. PAS is a second-line agent for TB.

Mechanism of action

PAS inhibits folic acid synthesis.

Pharmacokinetics

Orally absorbed. Doesn’t enter the CNS. Excreted by the kidney partly in unchanged form and partially as an acetylated metabolite.

Side effects

  • GI symptoms
  • Hypersensitivity

Ethionamide

Ethionamide is a derivative of isoniazid.

Indication

Second-line drug for TB.

Mechanism of action

Inhibits mycolic acid synthesis.

Pharmacokinetics

Orally absorbed and well distributed. Eliminated by biotransformation.

Side effects

  • GI symptoms
  • Hepatotoxicity
  • CNS effects
    • Depression
  • Hypersensitivity reaction

Cycloserine

Indication

Second-line drug for TB.

Mechanism of action

Inhibits peptidoglycan synthesis.

Pharmacokinetics

Orally absorbed and distributed. Excreted by the kidney.

Side effects

  • CNS toxicity
    • Headache
    • Convulsions

Bedaquiline and delamanid

Bedaquiline and delamanid are new (2012 and 2014, respectively) antituberculotic drugs. They’re used exclusively for multi-drug resistant TB.

Both these drugs cause prolongation of the QT interval, so the patient’s ECG must be closely monitored.

Anti-leprosy drugs

There are two types of leprosy: the tuberculoid type and the lepromatous type.

The therapy for the tuberculoid type is 6 months of dapsone and rifampin. The therapy for the lepromatous type is 12 – 24 months of dapsone, rifampin and clofazimine. Thalidomide is a second-line agent.

Rifampin was described above. Only dapsone and clofazimine will be discussed here.

Mechanism of action

Dapsone inhibits folic acid synthesis. Dapsone is related to the sulphonamides.

Clofazimine inhibits DNA replication and transcription.

Pharmacokinetics

Dapsone is orally absorbed and widely distributed. It’s metabolized in the liver and excreted by the kidney.

Clofazimine is orally absorbed. It accumulates in several tissues, giving it a tissue half-life of many weeks. It’s partially metabolized in the liver and partially excreted in bile in unchanged form.

Side effects

Dapsone:

  • GI symptoms
  • Haemolysis
    • Cannot be given to people with malaria or G6PD deficiency
  • Methaemoglobinaemia

Clofazimine:

  • GI symptoms
  • Reddish discoloration of body fluids, skin and conjunctiva
  • Blue-black discoloration of skin and mucous membrane