10. ntm standard treatment 2019 - ucsf fresno · 2019-10-30 · microsoft powerpoint - 10. ntm...

10/26/2019

2019 Lung Infection Symposium - Fayed IV 1

NTM Standard Treatment and New Therapy 2019

Mohamed A Fayed, MD

Pulmonary critical care faculty

UCSF Fresno

Disclosure

Speaker for Insmed Inc.

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Objectives

• What is the guideline and best practice in treatment of NTM lung disease

• New therapy available for NTM lung disease

Management of NTM

• Non pharmacological therapy

‒ Tobacco cessation

‒ Airway clearance

‒ Reduce exposure

‒ Exercise and nutrition

• Pharmacological therapy include Multidrug therapy

• Frequent monitoring

‒ Side effect

‒ Clinical symptoms

‒ Microbiological and culture conversion

‒ Radiological improvement

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Non pharmacological therapy

• Tobacco cessation if applicable

• Airway clearance

• Reduce exposure

• exercise and improve nutrition

Pharmacological therapy

• Initiating medication

‒ Oral therapy

‒ Inhaler therapy

‒ IV therapy

Frequent monitoring

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Non pharmacological therapy

Airway clearance

Airway clearance

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Airway clearance

Airway clearance

Nebulized solutions

• Hypertonic saline

• Bronchodilators

Assistance

• Manual percussion

• Postural positioning

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Exposure reduction

Avoid hot tubs

Change and clean shower heads

• Use filters < 0.45 microns on taps and showerheads

• Change showerheads every month or disinfect in bleach for 30 min

• Use large holes in showerhead

Avoid dust inhalation when gardening or cleaning in homes.

Wet soil to reduce aerosols.

Exposure reduction

•Avoid Humidifier •Regular cleaning – cleaning or disinfection (undiluted household bleach for 30 minutes)

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Guideline therapy

1.Am J Respir Crit Care Med Vol 175. pp 367–416, 20072. Haworth CS, et al. Thorax 2017;72:iii1–ii64. doi:10.1136/thoraxjnl-2017-210927

Drug therapy for MAC disease involves multiple drugs

• Choice of regimen depends on the species

• Sensitivity is needed to direct good regimen

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Slow growing NTM therapy

M.Avium complex (MAC)

• M.chimaera

• M.Avium

• M.Intercellulare

M. kansasii

M. xenopi

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Rapid growing NTM therapy

M. abscessus

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M. xenopi.

Non-severe pulmonary disease Severe pulmonary disease

1. Rifampicin 2. Ethambutol 3. Azithromycin 250mg daily4. Moxifloxacin 400mg daily or isoniazid

300mg

1. Rifampicin 2. Ethambutol 3. Azithromycin 250mg daily 4. Moxifloxacin 400mg daily or isoniazid

300mg (+pyridoxine 10mg) daily and5. Consider intravenous amikacin for up

to 3 months or nebulised amikacin

4 drugs therapy

Haworth CS, et al. Thorax 2017;72:ii1–ii64. doi:10.1136/thoraxjnl-2017-210927

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Mycobacterium abscessus

Treatment consists of initial phase followed by continuous phase

• Sensitivity classified into 2 groups

‒ Clarithromycin sensitive isolates or inducible macrolide-resistant isolates erm (41)

‒ Constitutive macrolide-resistant isolates

Haworth CS, et al. Thorax 2017;72:ii1–ii64. doi:10.1136/thoraxjnl-2017-210927

Initial phase for both groups (sensitive and resistant) 3 IV antibiotics for 4 weeks

• IV Amikacin plus

• IV tigecycline plus

• IV Imipenem

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Continuation phase (sensitive group)

• Nebulized Amikacin plus

• Oral azithromycin plus one the following (antibiotics guided by drug susceptibility results and patient tolerance)

‒ Clofazimine

‒ linezolid

‒ minocycline

‒ Moxifloxacin

‒ Trimethoprim-sulfamethoxazol

Continuation phase (Resistant group)

• Nebulized Amikacin plus

• 2–4 of the following antibiotics guided by drug susceptibility results

‒ clofazimine

‒ minocycline

‒ moxifloxacin

‒ Trimethoprim-sulfamethoxazole

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Follow up

Frequent monitoring

• Clinical improvement and side effect (usually 1-2 month then after 3-4 month if stable)

• Hearing testing every 6 month

• Eye exam especially if daily ethambutol

• Caution with fluoroquinolone related tendinopathy

• Neuropathy with linezolid

Follow up

• Laboratory monitoring

‒ CBC and CMP (1-2 month then every 3-4 month if stable)

‒ Amikacin level if IV is given

• Microbiological monitoring

‒ Sputum culture to demonstrate culture conversion (therapy is usually 12-18 month after culture conversion)

• Radiological monitoring

‒ CT scan to demonstrate improvement (frequency varies)

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Novel therapy

Arikayce, FDA approved for limited population in Sept 2018

• Limitation of use: Amikacin oral inhalation has only been studied in patients with refractory MAC lung disease defined as patients who did not achieve negative sputum cultures after a minimum of 6 consecutive months of a multidrug background regimen therapy

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Role of Surgery

Surgical resection for limited pulmonary disease may be curative, however, the decision to perform surgery should be made by clinicians with experience in the treatment of nontuberculous mycobacterial disease

Indications for considering lung surgery include poor response to drug therapy and significant disease-related complications, such as hemoptysis.

Thoracic surgery for M. abscessus infection, in particular, may be associated with significant complications even in expert hands and should only be performed in centers with extensive experience

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Summary

Treatment is multifactorial

• Non pharmacological therapy

‒ Airway clearance

‒ Tobacco cessation

‒ Reduce exposure

‒ Exercise and nutrition

• Pharmacological therapy include Multidrug therapy

• Frequent monitoring

‒ Side effect

‒ Clinical symptoms

‒ Microbiological and culture conversion

‒ Radiological improvement

Thank you!

10. ntm standard treatment 2019 - ucsf fresno · 2019-10-30 · microsoft powerpoint - 10. ntm...

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