Four-month moxifloxacin-based regimens for drug-sensitive tuberculosis

Abstract

Background: Early-phase and preclinical studies suggest that moxifloxacin-containing regimens could allow for effective 4-month treatment of uncomplicated, smear-positive pulmonary tuberculosis.

Methods: We conducted a randomized, double-blind, placebo-controlled, phase 3 trial to test the noninferiority of two moxifloxacin-containing regimens as compared with a control regimen. One group of patients received isoniazid, rifampin, pyrazinamide, and ethambutol for 8 weeks, followed by 18 weeks of isoniazid and rifampin (control group). In the second group, we replaced ethambutol with moxifloxacin for 17 weeks, followed by 9 weeks of placebo (isoniazid group), and in the third group, we replaced isoniazid with moxifloxacin for 17 weeks, followed by 9 weeks of placebo (ethambutol group). The primary end point was treatment failure or relapse within 18 months after randomization.

Results: Of the 1931 patients who underwent randomization, in the per-protocol analysis, a favorable outcome was reported in fewer patients in the isoniazid group (85%) and the ethambutol group (80%) than in the control group (92%), for a difference favoring the control group of 6.1 percentage points (97.5% confidence interval [CI], 1.7 to 10.5) versus the isoniazid group and 11.4 percentage points (97.5% CI, 6.7 to 16.1) versus the ethambutol group. Results were consistent in the modified intention-to-treat analysis and all sensitivity analyses. The hazard ratios for the time to culture negativity in both solid and liquid mediums for the isoniazid and ethambutol groups, as compared with the control group, ranged from 1.17 to 1.25, indicating a shorter duration, with the lower bounds of the 95% confidence intervals exceeding 1.00 in all cases. There was no significant difference in the incidence of grade 3 or 4 adverse events, with events reported in 127 patients (19%) in the isoniazid group, 111 (17%) in the ethambutol group, and 123 (19%) in the control group.

Conclusions: The two moxifloxacin-containing regimens produced a more rapid initial decline in bacterial load, as compared with the control group. However, noninferiority for these regimens was not shown, which indicates that shortening treatment to 4 months was not effective in this setting. (Funded by the Global Alliance for TB Drug Development and others; REMoxTB ClinicalTrials.gov number, NCT00864383.).

Figure 1. Enrollment and Outcomes

MDR denotes multidrug resistance.

Figure 2. Kaplan–Meier Estimates of the Time to an Unfavorable Outcome and Conversion to Culture-Negative Status

Panel A shows that the time until patients had an unfavorable outcome was shorter in the isoniazid group than in the control group (hazard ratio, 1.25 [97.5% CI, 1.08 to 1.42]) and was further reduced in the ethambutol group (hazard ratio, 1.21 [97.5% CI, 1.05 to 1.37]). Panel B shows the time until conversion to culture-negative status, which occurred sooner in the isoniazid group and the ethambutol group than in the control group, according to analyses of sputum samples cultured in Lowenstein–Jensen solid medium. Patients who were excluded from the primary per-protocol analysis were included in this analysis, but data were censored at the time of exclusion from the per-protocol analysis.