Addressing Latent Tuberculosis Infection Treatment Through a Collaborative Care Model With Community Pharmacies and a Health Department

Bernadette Jakeman, PharmD; Stefanie J. Logothetis, PharmD; Melissa H. Roberts, PhD; Amy Bachyrycz, PharmD; Diana Fortune, BSN; Matthew E. Borrego, PhD; Julianna Ferreira, MSN, MPH; Marcos Burgos, MD

Disclosures

Prev Chronic Dis. 2020;17(2):e14 

In This Article

Abstract and Introduction

Abstract

Introduction: The objective of this study was to evaluate a novel collaborative care model using community pharmacies as additional access points for latent tuberculosis infection (LTBI) treatment for patients using combination weekly therapy with isoniazid and rifapentine (3HP) plus directly observed therapy for 12 weeks.

Methods: This prospective pilot study included adult patients diagnosed with LTBI. Patients were eligible for study participation if they spoke English or Spanish and were followed by the New Mexico Department of Health (NM DOH). Patients were excluded if they were pregnant, receiving concomitant HIV antiretroviral therapy, or had contraindications to 3HP due to allergy or drug interactions. Community pharmacy sites included chain, independent, and hospital outpatient pharmacies in Albuquerque and Santa Fe, New Mexico.

Results: A total of 40 patients initiated treatment with 3HP and were included. Most were female (55%) and had a mean age of 46 years (standard deviation, 12.6 y). A total of 75.0% of patients completed LTBI treatment with 3HP in a community pharmacy site. Individuals of Hispanic ethnicity were more likely to complete treatment (76.7% vs 40.0%, P = .04). Most patients (60%; n = 24) reported experiencing an adverse drug event (ADE) with 3HP therapy. Patients who completed treatment were less likely to experience an ADE than patients who discontinued treatment (50.0% vs 90.0%, P = .03). Pharmacists performed 398 LTBI treatment visits (40 initial visits, 358 follow-up visits), saving the NM DOH approximately 143 hours in patient contact time.

Conclusion: High completion rates and safe administration of LTBI treatment can be achieved in the community pharmacy setting.

Introduction

Tuberculosis (TB) is a curable disease, yet it is the tenth leading cause of death worldwide, ranking above HIV.[1] TB disease resulted in an estimated 1.3 million deaths worldwide in 2017.[1] The World Health Organization has outlined a framework for TB elimination in low-incidence countries such as the United States.[2] Included in the TB elimination strategy is the identification and treatment of latent tuberculosis infection (LTBI) to prevent progression to and transmission of active disease.[2] Treatment of LTBI decreases illness and death associated with active TB disease[3] and is associated with less medication toxicity and cost compared with active TB disease treatment.[4–6] It is estimated that 13 million people have LTBI in the United States.[7] This large number of potential LTBI cases poses a serious public health challenge for successful TB control and elimination. Using community pharmacies is a possible strategy to expand access for testing and treatment.

In 2011, because of nursing resource limitations at the New Mexico Department of Health (NM DOH), tuberculin skin testing was made available in New Mexico community pharmacies.[8] As of 2016, more than 200 New Mexico pharmacists had been trained to provide this public health service, which provides testing access for patients in small city locations and has been widely used by patients across the state.[8,9] In 2017, the NM DOH TB program wanted to expand access to patients by also providing LTBI treatment in the community pharmacy setting.

In 2012 the NM DOH transitioned from LTBI treatment with isoniazid monotherapy to weekly combination therapy with isoniazid plus rifapentine (3HP). This short 12-week combination regimen is associated with higher completion rates and lower rates of hepatotoxicity.[10,11] However, the 3HP regimen is still associated with medication toxicity, drug–drug interactions, and nonadherence. Providing this once-weekly regimen in a community pharmacy setting is one potential option to address these issues.

Completion rates for LTBI vary considerably in the literature, ranging from 35%–90%, with higher completion rates generally reported with shorter treatment regimens.[10,12–17] Predictors for noncompletion include unstable housing, tobacco use, alcohol use, adverse drug events (ADEs), older age, patient location, poverty, and non-Hispanic ethnicity.[14,18–21]

Data evaluating the use of pharmacists in the treatment of LTBI are limited.[22–25] However, the available studies have reported high completion rates when a pharmacist was included in treatment management. Tavitian et al reported high completion rates (93%) associated with a pharmacist-managed clinic for treatment of LTBI with isoniazid monotherapy in health care workers.[22] Carter et al also reported high LTBI completion rates (94%) with a pharmacist-run clinic using monotherapy with either rifampin or isoniazid for refugee patients.[25] To our knowledge, administration of LTBI treatment in the community pharmacy setting has never been evaluated.

The primary objective of this study was to evaluate a novel and collaborative care model using community pharmacy sites to support increased patient access to LTBI treatment using combination weekly therapy with isoniazid 900 mg plus rifapentine 900 mg for 12 weeks. Secondary objectives were evaluation of treatment completion rates and ADEs.

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