Landmark clinical trial redefines multidrug-resistant TB treatment options

Paris, France, 15 November 2023 – Clinical trial results presented for the first time today at the Union World Conference on Lung Health revealed evidence to support the use of four new, improved regimens to treat multi-drug resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB). The team—led by Médecins Sans Frontières (MSF), Partners In Health (PIH), and Interactive Research and Development (IRD) and funded by Unitaid—formed the endTB consortium and began this Phase III randomized controlled trial in 2017.   

MDR/RR-TB is a disease caused by a TB bacterium that is resistant to rifampicin, one of the most powerful first-line antibiotics, plus/minus resistance to isoniazid. Roughly half a million people fall sick with MDR/RR-TB each year, and many die from it. Though a range of MDR-TB regimens are now in use around the world, many people are still treated with conventional treatments that are long (up to 24 months), ineffective (only 59% treatment success in 2018), and often cause terrible side effects, including acute psychosis and permanent deafness. Patients on these regimens must ingest up to 14,000 pills over the full course of treatment, and some have to endure months of painful, daily injections.  

The trial found three new drug regimens that can deliver similar efficacy and safety to conventional treatments while reducing treatment time by up to two-thirds. The endTB regimens represent important alternatives for short MDR-TB treatment and complement the use of another highly effective, shorter MDR-TB regimen, called BPaLM, which is not suitable for certain populations. If recommended by the World Health Organization, these new patient-centered treatment regimens would empower clinicians to offer shortened MDR-TB treatment regardless of age, pregnancy, and comorbidities that are common among people with MDR-TB.   

In addition, the trial supports the use of a fourth regimen as an alternative for people who cannot tolerate bedaquiline or linezolid; at least one of these two drugs is in every current World Health Organization-recommended regimen for MDR-TB.   

The endTB trial enrolled a diverse group of 754 patients from seven countries (Georgia, India, Kazakhstan, Lesotho, Pakistan, Peru, and South Africa). This included historically excluded populations like adolescents and those with comorbidities like substance-use disorders, and retained participants who became pregnant during the trial. The trial evaluated five nine-month treatment regimens, and randomization was outcome-adapted, meaning more patients were assigned to regimens that were producing better outcomes.   

“We stand on the cusp of a significant breakthrough in the battle against MDR, a disease that disproportionately affects impoverished populations around the globe. Our results offer hope to those in dire need and underscore the urgency of continued research and innovation—and accountability of private companies that receive public funds—to address diseases that too often strike the most vulnerable among us. But the cost of some drugs remains a barrier. One example is delamanid which is still priced at 12-40 times higher than it should be according to an independently estimated cost to produce the drug,” said Carole Mitnick, ScD, Partners In Health Director of Research for the endTB project, Co-Principal Investigator of the study, and Professor of Global Health and Social Medicine at Harvard Medical School.   

“For far too long, MDR-TB has loomed as a formidable threat with limited, poorly tolerated treatment options, but today, we unveil evidence for multiple innovative all-oral, shortened regimens that will allow patient-centered, individualized treatment of MDR-TB. This marks a pivotal moment in the fight against a disease that has plagued vulnerable populations worldwide. What makes these results even more remarkable is the diversity, and resulting generalizability, of this Phase III randomized controlled trial,” said Lorenzo Guglielmetti, MD, Médecins Sans Frontières Director for the endTB project and Co-Principal Investigator of the study.   

“These results provide new hope for all those awaiting treatment for the most dangerous and difficult to treat forms of tuberculosis worldwide,” said Dr Philippe Duneton, Executive Director of Unitaid. “We have the gold-standard research. The drugs are already available where they are needed. If recommended, this high-quality evidence could quickly translate into better treatment options suitable for all people with drug-resistant tuberculosis.”  

The endTB clinical trial evaluated five experimental regimens for MDR/RR-TB against the standard of care in two distinct analysis populations. endTB regimens 1, 2, 3, demonstrated non-inferiority to the control in both primary analysis populations, establishing their success in treating RR-TB. Regimens 1, 2, and 3 achieved favorable outcomes in 89.0%, 90.4%, and 85.2% of participants, respectively. Regimen 5 also showed a strong treatment response at 85.6% and was non-inferior to the control’s 80.7% in one of the primary analysis populations. While consistent results in both populations are needed to formally establish non-inferiority, regimen 5 holds promise as an alternative for patients unable to receive other recommended treatments.  

True access to these new treatment options depends on removing all barriers to timely and high-quality care. These trial results could address a major barrier to care for many people and the endTB consortium will continue to advocate to improve access and affordability to quality TB care. 

Download a leaflet on the endTB clinical trial results here.

Watch a short video on the endTB clinical trial results here.

For further details about the endTB clinical trial results, visit endTB.org.

About UNITAID 

Unitaid saves lives by making new health products available and affordable for people in low- and middle-income countries. Unitaid works with partners to identify innovative treatments, tests and tools, helps tackle the market barriers that are holding them back, and gets them to the people who need them most – fast. Since it was created in 2006, Unitaid has unlocked access to more than 100 groundbreaking health products to help address the world’s greatest health challenges, including HIV, TB, and malaria; women’s and children’s health; and pandemic prevention, preparedness and response. Every year, these products benefit more than 170 million people. Unitaid is a hosted partnership of the World Health Organization.  

About MSF 

Médecins Sans Frontières / Doctors Without Borders (MSF) is an international, independent, medical humanitarian organization that delivers emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare. Today, MSF has operations in nearly 70 countries. 

MSF has been involved in tuberculosis care for over 30 years and opened its first programmes to treat multidrug-resistant TB in 1999. MSF has TB treatment projects in 30 countries; it is one of the largest non-governmental providers of treatment for drug-resistant TB. In 2022, 17,800 people started first-line treatment for tuberculosis in MSF programmes worldwide; 2,590 patients started drug-resistant tuberculosis treatment. For more information, visit: www.msf.org.  

About PIH 

Partners In Health is a global health organization relentlessly committed to improving the health of the poor and marginalized. PIH builds local capacity and work closely with impoverished communities to deliver high-quality health care, address the root causes of illness, train providers, advance research, and advocate for global policy change. PIH began treating MDR-TB in 1995 and has since implemented community-based treatment programs for MDR-TB in multiple countries, including Peru, Russia, Haiti, Lesotho and Kazakhstan. For more information, visit: www.pih.org. 

About IRD 

IRD is a global health delivery and research organization based in Dubai that works in 15 countries, including high-burden MDR-TB countries such as Pakistan, Indonesia, and Bangladesh. The IRD team leverages process and technology innovations to address global health delivery gaps, including the use of health market innovations such as social business models to engage private providers in lung health and diabetes care, as well as the use of performance-based incentives for community screeners and treatment supporters, patient incentives to enable treatment compliance, and the use of open source information technology platforms to allow close monitoring of patient care and program quality. For more information, visit www.ird.global.

Source: Unitaid