Latent tuberculosis infection treatment regimens — MSF Tuberculosis

What this guideline says

GMJ summary

Médecins Sans Frontières recommends three primary regimens for latent tuberculosis infection (LTBI): isoniazid monotherapy for 6 months (6H) or 36 months in specific populations (36H); isoniazid plus rifapentine weekly for 3 months (3HP); or isoniazid plus rifampicin daily for 3 months (3HR). Two alternative regimens are also available: isoniazid plus rifapentine daily for 1 month (1HP) for those aged ≥13 years, and rifampicin monotherapy for 4 months (4R).

The choice of regimen depends on the drug susceptibility of the source case, co-morbidities including HIV infection, risk of drug interactions (especially with antiretrovirals), treatment duration, likelihood of adherence, and individual patient characteristics such as age and pregnancy status. Shorter regimens (3HP, 3HR, 1HP) generally have higher completion rates than 6-month isoniazid monotherapy, though rifapentine-containing regimens are not currently recommended for pregnant women.

Persons at risk of peripheral neuropathy should receive pyridoxine (vitamin B6) throughout isoniazid treatment. Rifamycin-containing regimens have significant drug interactions, particularly with antiretrovirals and contraceptives, and pregnant women taking rifampicin should receive phytomenadione (vitamin K) in the final weeks of pregnancy.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Isoniazid monotherapy: <30 kg receive 10 mg/kg (7–15 mg/kg) once daily, ≥30 kg receive 5 mg/kg (4–6 mg/kg) once daily (maximum 300 mg daily) for 6 months (or 36 months in some HIV-positive populations)
2. 3HP regimen (weekly for 3 months): isoniazid 20–30 mg/kg (<30 kg, ≥2 years) or 900 mg (≥30 kg) plus rifapentine 300–900 mg based on weight bands; recommended for children ≥2 years, adolescents and adults regardless of HIV status
3. 3HR regimen (daily for 3 months): isoniazid and rifampicin at standard doses; recommended for all ages including pregnant women, with fixed-dose combinations available
4. 1HP regimen (daily for 1 month, alternative): isoniazid 300 mg plus rifapentine 600 mg for those ≥13 years; high completion rate but cutaneous reactions common
5. 4R regimen (daily for 4 months, alternative): rifampicin monotherapy at 15 mg/kg (<30 kg) or 10 mg/kg (≥30 kg), maximum 600 mg daily; better safety profile than 6H but risk of rifampicin resistance if active TB undiagnosed
6. Pyridoxine (vitamin B6) should be given to all persons at risk of peripheral neuropathy receiving isoniazid for the entire treatment duration
7. Rifapentine-containing regimens are not currently recommended for pregnant women; 3HR and 4R regimens are safe in pregnancy with phytomenadione (vitamin K) in late pregnancy
8. Hypersensitivity reactions occur in approximately 4% of patients on 3HP and 2% on 3HR; rifamycin regimens have significant drug interactions with antiretrovirals and contraceptives

LTBI treatment regimens

Table extracted from the guideline

Source: Médecins Sans Frontières, Latent tuberculosis infection treatment regimens — MSF Tuberculosis. Reproduced in summary form.

From the guideline

Verbatim

“The decision to prescribe one regimen rather than the other should take into consideration: Drug-susceptibility of the strain of the presumed source patient, if known.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

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