COMMENTARY

Latent TB: Updated Treatment Recommendations

Philip S. LoBue, MD

Disclosures

December 17, 2018

Editorial Collaboration

Medscape &

Hello. I'm Dr Philip LoBue, director of the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention. I'm pleased to speak with you as part of CDC's Expert Video Commentary series on Medscape.

Today I would like to share important information about the latest recommendations for treating latent tuberculosis infection (TBI). Treatment of latent TBI is essential to controlling and eliminating TB in the United States. Up to 13 million people in the United States have latent TBI.[1] People with latent TBI do not feel sick or show symptoms, and cannot spread TB bacteria to others. A diagnosis of latent TBI is made if a person has a positive interferon gamma release assay (IGRA) or TB skin test result and a medical evaluation does not indicate TB disease.[2]

Without treatment, about 1 in 10 people with latent TBI will develop TB disease at some point in their lives. For some, such as people with immunocompromising conditions or who are taking certain medications, that risk is higher.[3] Treatment greatly reduces this risk. There are several, equally effective treatment regimens for latent TBI. Clinicians should prescribe the more convenient shorter regimens when possible, because patients are more likely to complete them.

CDC has released updated recommendations[4] on the shortest of the available regimens for treating latent TBI: 3 months of a combination of isoniazid (H) and rifapentine (P). This regimen, often referred to as 3HP, is taken once weekly for 12 weeks. Clinicians can now prescribe 3HP to patients as self-administered therapy. Previously, 3HP had to be administered by directly observed therapy, with a healthcare worker observing each dose. Self-administered therapy can be more convenient for patients and clinicians.

The updated recommendations are also good news for two groups of patients who have a higher risk of developing TB disease once infected: children and people with HIV/AIDS. CDC continues to recommend treatment for people age 12 and older, and now recommends 3HP for children aged 2-11 years. CDC also recommends 3HP for people with latent TB infection and HIV/AIDS who are taking antiretroviral medications, such as efavirenz and raltegravir, which have acceptable drug interactions with rifapentine.

3HP is not recommended for persons less than 2 years of age, people with HIV/AIDS taking antiretroviral medications with clinically significant drug interactions with once-weekly rifapentine, pregnant women, women expecting to become pregnant during treatment, or persons infected with TB bacteria that is presumed to be isoniazid- or rifampin-resistant.

Prior to beginning 3HP, clinicians should evaluate patients for signs and symptoms of active TB disease. Clinicians should also consider conducting liver function tests for certain patients. It is important that clinicians educate patients about possible adverse events, and instruct patients to use a symptom checklist and medication intake log during treatment. CDC has guidance and resources for clinicians on patient education and monitoring. Clinicians should also follow CDC guidance on early detection and management of adverse events.

CDC encourages clinicians to test patients who are at increased risk for TB infection.[5] These include persons born in or who frequently travel to countries where TB disease is common and people who currently or used to live in large group settings. Clinicians should work with patients with latent TB infection to determine the best treatment regimen and provide support and resources to help patients complete treatment.

The United States has made great progress toward the goal of TB elimination. Treating latent TBI infection can help turn elimination into a reality. Our public health system and private providers play a crucial role in this effort to expand testing and treatment for latent TB infection, especially within high-risk communities.

For more information and additional resources on treatment for latent TBI, please visit the CDC website on TB.

Web Resources

CDC: Treatment Regimens for Latent TB Infection (LTBI)

CDC: The 12-Dose Regimen for Latent TB Infection Treatment: Fact Sheet for Clinicians

CDC: Frequently Asked Questions on the 12-dose regimen for Latent TB Infection for Providers

Frequently Asked Questions on the 12-dose regimen for Latent TB Infection for Pharmacists

CDC: 12-Dose Regimen for Latent TB Infection Patient Education Materials (available in English, Spanish, Tagalog, and Vietnamese)

CDC: 12-Dose Regimen for Latent TB Infection-Patient Education Brochure

CDC: 12-Dose Regimen for Latent TB Infection-Medication Tracker and Symptom Checklist

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