Adherence to tuberculosis treatment
- Lee B Reichman, MD, MPH
Lee B Reichman, MD, MPH
- Professor of Medicine
- New Jersey Medical School
- Alfred A Lardizabal, MD
Alfred A Lardizabal, MD
- Associate Professor of Medicine
- New Jersey Medical School
Tuberculosis (TB) is nearly always curable if patients are treated with effective, uninterrupted antituberculous therapy. Adherence to treatment is critical for cure of individual patients, controlling spread of infection, and minimizing the development of drug resistance .
Issues related to adherence to treatment of drug-sensitive TB in adults will be reviewed here. The clinical approach to treatment of TB is discussed in detail separately. (See "Treatment of drug-susceptible pulmonary tuberculosis in HIV-uninfected adults" and "Treatment of pulmonary tuberculosis in HIV-infected adults" and "Treatment and prevention of drug-resistant tuberculosis" and "Diagnosis and treatment of extensively drug-resistant tuberculosis".)
CHALLENGES OF ADHERENCE
Incomplete adherence to treatment has been identified as the most serious problem in tuberculosis (TB) control  and a major obstacle to the elimination of the disease . In one retrospective study including 184 patients with TB in New York City (nearly half of whom were nonadherent), the nonadherent patients took longer to convert sputum to negative culture results (254 versus 64 days), were more likely to acquire drug resistance (relative risk 5.6), and required longer treatment regimens (560 versus 324 days) .
Adherence to tuberculosis treatment can be particularly challenging; the duration of treatment is long (usually six months or longer), combination therapy is required, and side effects may be unpleasant. Cost of medications (even relatively small copays or deductibles) can be a serious barrier to adherence if not covered by the public health system. Furthermore, patients often experience rapid improvement in symptoms, which may obfuscate the importance of continuing prolonged treatment with drugs that may be perceived as unnecessary.
Factors affecting adherence — Successful treatment among patients with TB may be influenced by several factors:
- Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147.
- Addington WW. Patient compliance: the most serious remaining problem in the control of tuberculosis in the United States. Chest 1979; 76:741.
- Mason JO. Opportunities for the elimination of tuberculosis. Am Rev Respir Dis 1986; 134:201.
- Pablos-Méndez A, Knirsch CA, Barr RG, et al. Nonadherence in tuberculosis treatment: predictors and consequences in New York City. Am J Med 1997; 102:164.
- Sbarbaro JA. The patient-physician relationship: compliance revisited. Ann Allergy 1990; 64:325.
- Moro RN, Borisov AS, Saukkonen J, et al. Factors Associated With Noncompletion of Latent Tuberculosis Infection Treatment: Experience From the PREVENT TB Trial in the United States and Canada. Clin Infect Dis 2016; 62:1390.
- Miller B, Snider DE Jr. Physician noncompliance with tuberculosis preventive measures. Am Rev Respir Dis 1987; 135:1.
- Essential components of a tuberculosis prevention and control program. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Recomm Rep 1995; 44:1.
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Tuberculosis Elimination. Module 6: Managing Tuberculosis Patients and Improving Adherence. Centers for Disease Control and Prevention, Atlanta, GA 2014. http://www.cdc.gov/tb/education/ssmodules/pdfs/module6v2.pdf (Accessed on January 21, 2015).
- Massachusetts Tuberculosis Nursing Case Management Protocols. Tuberculosis Elimination Achieved through Management. http://www.mass.gov/eohhs/docs/dph/cdc/tb/nursing-case-protocols.pdf (Accessed on January 21, 2015).
- Chaulk CP, Kazandjian VA. Directly observed therapy for treatment completion of pulmonary tuberculosis: Consensus Statement of the Public Health Tuberculosis Guidelines Panel. JAMA 1998; 279:943.
- Volmink J, Garner P. Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment. BMJ 1997; 315:1403.
- Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for tuberculosis. JAMA 1995; 274:945.
- Weis SE, Slocum PC, Blais FX, et al. The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis. N Engl J Med 1994; 330:1179.
- Zwarenstein M, Schoeman JH, Vundule C, et al. Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis. Lancet 1998; 352:1340.
- Walley JD, Khan MA, Newell JN, Khan MH. Effectiveness of the direct observation component of DOTS for tuberculosis: a randomised controlled trial in Pakistan. Lancet 2001; 357:664.
- Hill AR, Manikal VM, Riska PF. Effectiveness of directly observed therapy (DOT) for tuberculosis: a review of multinational experience reported in 1990-2000. Medicine (Baltimore) 2002; 81:179.
- Karumbi J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev 2015; :CD003343.
- Moulding T, Dutt AK, Reichman LB. Fixed-dose combinations of antituberculous medications to prevent drug resistance. Ann Intern Med 1995; 122:951.
- Buchanan RJ. Compliance with tuberculosis drug regimens: incentives and enablers offered by public health departments. Am J Public Health 1997; 87:2014.
- Lutge EE, Wiysonge CS, Knight SE, et al. Incentives and enablers to improve adherence in tuberculosis. Cochrane Database Syst Rev 2015; :CD007952.
- Salomon N, Perlman DC, Rubenstein A, et al. Implementation of universal directly observed therapy at a New York City hospital and evaluation of an out-patient directly observed therapy program. Int J Tuberc Lung Dis 1997; 1:397.
- Burman WJ, Cohn DL, Rietmeijer CA, et al. Noncompliance with directly observed therapy for tuberculosis. Epidemiology and effect on the outcome of treatment. Chest 1997; 111:1168.
- Gasner MR, Maw KL, Feldman GE, et al. The use of legal action in New York City to ensure treatment of tuberculosis. N Engl J Med 1999; 340:359.
- Singleton L, Turner M, Haskal R, et al. Long-term hospitalization for tuberculosis control. Experience with a medical-psychosocial inpatient unit. JAMA 1997; 278:838.
- Oscherwitz T, Tulsky JP, Roger S, et al. Detention of persistently nonadherent patients with tuberculosis. JAMA 1997; 278:843.
- Lerner BH. Catching patients: tuberculosis and detention in the 1990s. Chest 1999; 115:236.
- CHALLENGES OF ADHERENCE
- Factors affecting adherence
- Risk factors for nonadherence
- STRATEGIES TO IMPROVE ADHERENCE
- Comprehensive case management
- Directly observed therapy
- Fixed-dose combination therapy
- Patient education
- Incentives and enablers
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS