ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Adherence to tuberculosis treatment

Adherence to tuberculosis treatment
Literature review current through: Jan 2024.
This topic last updated: May 26, 2023.

INTRODUCTION — 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 [1,2].

Issues related to adherence to treatment of drug-susceptible 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 nonpregnant adults without HIV infection" and "Treatment of drug-susceptible pulmonary tuberculosis in nonpregnant adults with HIV infection: Initiation of therapy" and "Treatment of drug-resistant pulmonary tuberculosis in adults".)

CHALLENGES OF ADHERENCE — Incomplete adherence to treatment has been identified as the most serious problem in TB control [3] and a major obstacle to the elimination of the disease [4]. 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) [5].

Adherence to TB 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:

Severity of symptoms

Access to medical care

Number of medications and their side effects

Availability and cost of medications (to the patient)

Dosing frequency

Duration of treatment

Personal and social characteristics of patients and providers

Cultural beliefs of patients and providers and trust in the diagnosis

Cultural sensitivity of providers and the relationship between provider and patient

Quality of training among providers

Quantity and quality of information available about TB

Extent of patient knowledge about TB and the importance of completing a lengthy treatment regimen even if feeling well

Commitment of public health system to TB treatment

Political, legislative, and economic factors

Health care providers must evaluate potential obstacles to treatment and facilitate educating and supporting patients to take medications as prescribed. A poor caregiver-patient relationship is an important cause of nonadherence.

Risk factors for nonadherence — In general, up to half of patients do not follow medical recommendations or use medications as prescribed [6,7]. No single group has been consistently identified to be at risk for nonadherence; the following patients may benefit from close monitoring:

Patients who have previously failed to complete a regimen of antituberculous therapy (for treatment of active disease or latent infection) or who have had difficulty complying with other medical therapies

Physically, emotionally, or socioeconomically challenged patients

Patients unable to pay for medications

Patients actively abusing drugs, alcohol, or other addictive substances

Patients who do not believe they have TB or who do not understand the importance of treatment and/or have cultural beliefs opposing treatment

In one series of patients with TB in New York City, an increased rate of nonadherence was observed among African-Americans, people who inject drugs, people experiencing homelessness, people with alcohol use disorder, and people with human immunodeficiency virus (HIV) infection [5]. Multivariate analysis noted that the only consistent predictors of nonadherence were injection drug use and homelessness.

Physicians and other health care workers also have difficulties with adherence [8].

STRATEGIES TO IMPROVE ADHERENCE — Treatment strategies should employ a patient-centered case management approach, using directly observed therapy (DOT) as a tool to maximize adherence [1]. Case management with DOT (at least at the start of treatment) using trained nurses has become a standard of care in TB control and prevention [9]. Other strategies include provision of free medications, use of fixed dose multiple drug combination tablets, patient education, and vouchers for transportation and other needs.

Comprehensive case management — Using this strategy, teams of personnel assume responsibility for case management, continuity of care, and follow-up. Each TB case or suspect is assigned a public health case manager who is responsible for coordinating all aspects of that patient’s care, usually giving the patient a major voice in deciding how care is administered. Description of this strategy are contained in the United States Centers for Disease Control and Prevention (CDC) module on TB: "Managing Tuberculosis Patients and Improving Adherence" [10] the publication by the Rutgers Global TB Institute: Tuberculosis Case Management: A Guide for Nurses (2017) [11].

Patient education — Patient education that is culturally and linguistically appropriate (in combination with other interventions) while minimizing stigmatization is essential for ensuring adherence. The use of simple terms together with both written and pictorial materials are all important. Educational efforts should be directed at identifying the patient's perception of barriers to adherence and at building trust with the health care delivery system.

Use of fixed-dose combination therapy — The use of fixed-dose combinations of antituberculous drugs simplifies therapy and reduces the possibility of missing a component of a multidrug regimen. These preparations reduce the likelihood of acquired drug resistance and are widely used around the world [12]. Combination drugs in the United States have included Rifamate (isoniazid plus rifampin) and Rifater (isoniazid, rifampin, and pyrazinamide); however, their production was discontinued by their manufacturer in June 2020.

Directly or video observed therapy

Definition and use - Directly observed therapy (DOT) involves observation by a health care provider watching as a patient swallows each dose of antituberculous medication [1,13]. We are in agreement with the 2016 American Thoracic Society, United States Centers for Disease Control (CDC), and Infectious Diseases Society of America guidelines, which suggest using DOT (rather than self-administered therapy) for routine treatment of patients for all forms of TB [1]. In March 2023, the CDC updated this recommendation to include video DOT (vDOT) as an equivalent alternative to in-person DOT [14].

Prioritizing DOT resources - If routine DOT is not feasible, it should be prioritized for patients with the conditions summarized in the table (table 1). Decisions regarding implementation of observed therapy may be based on local rates of treatment completion and individual patient circumstances. In many programs, patients are observed taking their medications on weekdays and self-administer medications on weekends.

Efficacy

DOT - DOT programs require a significant commitment of resources but have been shown to be very effective [13,15-17]. One study of the community-based DOT program in Baltimore, Maryland, illustrated the benefits derived from DOT; during the 1980s and early 1990s, Baltimore experienced a substantial decline in TB incidence while TB incidence elsewhere in the United States increased [16].

Some studies have observed that DOT did not alter rates of cure, treatment interruption, or other outcomes [18,19]. A systematic review of the effectiveness of DOT including 34 studies found that, while overall rates of treatment failure and relapse were low, considerable variability among studies existed in actual compliance and follow-up [20]. A subsequent systematic review including six trials in five mostly high-TB incidence countries concluded that DOT alone did not offer benefit over self-administered care [21]. DOT must be considered a key component of an active case management system in which individual relationships between caregivers and patients form the basis for a treatment plan to ensure safe continuity of treatment.

Video DOT (vDOT) – The growth of technology has created new opportunities to deliver care via vDOT for patients with TB. vDOT systems must meet jurisdictional privacy requirements. Several studies in high- and low-resource settings have shown that vDOT is feasible, cost-effective, and effective [22-26]. In one randomized trial including more than 220 patients with TB in England managed with observed therapy via DOT (observations three to five times per week in the home, community, or clinic settings) or vDOT (daily observation using via mobile phone), completion of ≥80 percent of scheduled observations during the first two months after enrollment was achieved more frequently among patients on vDOT than among patients on DOT (70 versus 31 percent; adjusted odds ratio 5.48, 95% CI 3.10-9.68) [26]. More than half of enrolled patients had a history of homelessness, imprisonment, drug or alcohol use, or mental health problems.

Digital reminders — For settings in which case management with observed therapy is not feasible, use of digital reminders may be beneficial. In a randomized trial in Kenya including more than 1100 patients with TB managed with or without use of interactive text message reminders to take therapy, rates of unsuccessful treatment outcomes were lower among patients who received digital reminders (4.2 versus 13.1 percent) [27].

Incentives and enablers — Incentives and enablers are used to encourage treatment adherence. Incentives are small "rewards" given to patients who adhere to the prescribed treatment regimen and maintain regular clinic visits. Enablers allow the patient to receive treatment more easily (eg, bus tickets or other means of transportation).

Incentives (such as food supplements, food vouchers, cash, and clothing) may be provided to patients to optimize nutrition and cover personal costs for travel and missing work [28]. Material incentives and enablers may have some positive short-time effects on clinic attendance, particularly for marginal populations, but there is insufficient evidence to know if they can improve long-term adherence to TB treatment [29]. Some data suggest that illicit drug users adhere to DOT at equal or higher rates than other patients if appropriate incentives and enablers are offered [30].

Hospitalization — Outpatient treatment with DOT may not be sufficient for adherence in some cases [31,32]. In such circumstances, long-term hospitalization (voluntary or involuntary) may be necessary. In one series of 166 patients in Massachusetts, a dedicated medical-psychosocial inpatient unit facilitated completion of therapy in 97 percent of cases; hospitalization was required for the duration of therapy in 25 percent of cases [33]. Among 67 nonadherent patients in California detained in prison rather than a hospital ward, a lower completion rate was observed (84 percent) [34]. Involuntary confinement is a strategy of last resort [35].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diagnosis and treatment of tuberculosis".)

SUMMARY AND RECOMMENDATIONS

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. (See 'Introduction' above.)

Incomplete adherence to treatment has been identified as the most serious problem in TB control and a major obstacle to elimination. Treatment adherence can be particularly challenging in the setting of TB; the duration of treatment is long (usually six months or longer), combination therapy is required, and side effects may be unpleasant. (See 'Challenges of adherence' above.)

Patients at risk for nonadherence include those who have previously failed to complete a regimen of antituberculous therapy, those with physical or mental disability, those unable to pay for medications, those who are actively abusing addictive substances, and those who do not understand the importance of treatment and/or have cultural beliefs opposing treatment. (See 'Risk factors for nonadherence' above.)

Strategies to improve adherence include patient-centered care through comprehensive case management, directly observed therapy (DOT), provision of free medications, use of fixed-dose multidrug combination therapy if feasible, patient education and involvement in management decisions, and vouchers for transportation and other needs. (See 'Strategies to improve adherence' above.)

Directly observed therapy requires observation by a health care provider as a patient swallows each dose of antituberculous medication; this may be done in person or by video. We recommend using DOT (rather than self-administered therapy) for patients with the conditions summarized in the table (table 1) (Grade 1B). In addition, we suggest using DOT (rather than self-administered therapy) for routine treatment of patients for all forms of TB (Grade 2C). Video observed therapy is a reasonable alternative to DOT in settings where feasible. (See 'Directly or video observed therapy' above.)

  1. 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.
  2. World Health Organization. Guidelines for treatment of drug-susceptible tuberculosis and patient care, 2017 update. http://apps.who.int/iris/bitstream/10665/255052/1/9789241550000-eng.pdf?ua=1 (Accessed on June 08, 2017).
  3. Addington WW. Patient compliance: the most serious remaining problem in the control of tuberculosis in the United States. Chest 1979; 76:741.
  4. Mason JO. Opportunities for the elimination of tuberculosis. Am Rev Respir Dis 1986; 134:201.
  5. 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.
  6. Sbarbaro JA. The patient-physician relationship: compliance revisited. Ann Allergy 1990; 64:325.
  7. 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.
  8. Miller B, Snider DE Jr. Physician noncompliance with tuberculosis preventive measures. Am Rev Respir Dis 1987; 135:1.
  9. 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.
  10. 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).
  11. Rutgers Global Tuberculosis Institute. TUBERCULOSIS CASE MANAGEMENT: A GUIDE FOR NURSES. http://globaltb.njms.rutgers.edu/products/TB%20Nurse%20Case%20Management/Nurse%20Case%20Management%20Guide.pdf (Accessed on January 19, 2021).
  12. Moulding T, Dutt AK, Reichman LB. Fixed-dose combinations of antituberculous medications to prevent drug resistance. Ann Intern Med 1995; 122:951.
  13. 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.
  14. Mangan JM, Woodruff RS, Winston CA, et al. Recommendations for Use of Video Directly Observed Therapy During Tuberculosis Treatment - United States, 2023. MMWR Morb Mortal Wkly Rep 2023; 72:313.
  15. Volmink J, Garner P. Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment. BMJ 1997; 315:1403.
  16. Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for tuberculosis. JAMA 1995; 274:945.
  17. 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.
  18. Zwarenstein M, Schoeman JH, Vundule C, et al. Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis. Lancet 1998; 352:1340.
  19. 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.
  20. 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.
  21. Karumbi J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev 2015; :CD003343.
  22. Mirsaeidi M, Farshidpour M, Banks-Tripp D, et al. Video directly observed therapy for treatment of tuberculosis is patient-oriented and cost-effective. Eur Respir J 2015; 46:871.
  23. Garfein RS, Collins K, Muñoz F, et al. Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study. Int J Tuberc Lung Dis 2015; 19:1057.
  24. Chuck C, Robinson E, Macaraig M, et al. Enhancing management of tuberculosis treatment with video directly observed therapy in New York City. Int J Tuberc Lung Dis 2016; 20:588.
  25. Hoffman JA, Cunningham JR, Suleh AJ, et al. Mobile direct observation treatment for tuberculosis patients: a technical feasibility pilot using mobile phones in Nairobi, Kenya. Am J Prev Med 2010; 39:78.
  26. Story A, Aldridge RW, Smith CM, et al. Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: a multicentre, analyst-blinded, randomised, controlled superiority trial. Lancet 2019; 393:1216.
  27. Yoeli E, Rathauser J, Bhanot SP, et al. Digital Health Support in Treatment for Tuberculosis. N Engl J Med 2019; 381:986.
  28. Buchanan RJ. Compliance with tuberculosis drug regimens: incentives and enablers offered by public health departments. Am J Public Health 1997; 87:2014.
  29. Lutge EE, Wiysonge CS, Knight SE, et al. Incentives and enablers to improve adherence in tuberculosis. Cochrane Database Syst Rev 2015; :CD007952.
  30. 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.
  31. 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.
  32. 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.
  33. 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.
  34. Oscherwitz T, Tulsky JP, Roger S, et al. Detention of persistently nonadherent patients with tuberculosis. JAMA 1997; 278:843.
  35. Lerner BH. Catching patients: tuberculosis and detention in the 1990s. Chest 1999; 115:236.
Topic 8019 Version 30.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟