Nouveaux antituberculeux Vincent Jarlier CNR des mycobactéries et de la résistance aux antituberculeux (CNR-MyRMA) Pitié-Salpêtrière, Paris

A « new » antituberculous agent : moxifloxacin

Fluoroquinolone activity In the mice (Lalande AAC 1993, Ji AAC 1995, Ji AAC 1998) FQ J0 CFU reduction (log) at week 4 (spleen) Ofloxacin 200 mg/kg 7,4 - 0,9 Levofloxacin 200 mg/kg - 2,4 Sparfloxacin 100 mg/kg 6,8 - 4,3 Moxifloxacin 100 mg/kg - 4,8 Man : early bactericidal activity : (EBA) equivalent to that of RMP but less than that of INH (Gosling AJRCCM 2003)

Moxifloxacin in MDR TB treatment in mice amikacin + ethionamide + pyrazinamide (AEtZ) + fluoroquinolone Mean UFC in lungs Day 0 6 months Moxifloxacin 12 months Veziris AAC 2003 WHO standard

Sterilizing activity in MDR TB (mice) : relapse 3 months after end of treatment % relapses Veziris ICAAC 2008 6 months : 58% 9-12 months required gold standard  40% 28% 16% 11% 11% 2RHZ +4RH 2JRZ +2JR 2AEtMZ +4EtM 2JAEtMZ +4JEtM 2JMZ +2JM 2JMZ +4JM 5

Moxifloxacin in daily treatment of susceptible TB (with RMP or INH) (1) Negativation of organs Nuermberger AJRCCM 2004 2MHZ + 4MH Untreated 2RHM+ 4RH 2HRMZ + 4HRM 2RHZ + 4RH 2RMZ + 4RM

Treatment length (months) Moxifloxacin in daily treatment of susceptible TB (with RMP or INH) in mice (2) Relapses 3 months after treatment completion Treatment length (months) Regimen 3 4 5 6 2RHZ/4RH 11/12* 5/12 1/16 0/12 1RMZ/RM 4/12 - 2RMZ/RM 2/12 0/13 RMZ *proportion of mice whose organs yielded positive cultures Nuermberger AJRCCM 2004

Moxifloxacin in man Burman AJRCCM 2006 HRZ + ethambutol or moxifloxacine (2 groups) 336 patients, 277 (82%) evaluable 206 (74%) with caverna 60 (22%) HIV+ 71% culture negativation at 2 months in both groups More culture negativation at 1 month with moxifloxacin more nausea (22 vs 9%) with moxifloxacin Same rate of lost of follow up Burman AJRCCM 2006

Moxifloxacin in man HRZ + éthambutol or moxifloxacine 170 patients, 146 evaluable Chaisson ICAAC 2007 % cultures neg p=0.021 weeks

Moxifloxacin in man P = 0,37  deceiving HRE + isoniazid or moxifloxacin 433 patients, 344 (79%) evaluable 252 (73%) with caverna 36 (11%) HIV+ 60% (103/171) negativation after 2 months with moxifloxacin 55% (93/173) negativation after 2 months with isoniazid P = 0,37  deceiving Dorman, ICAAC 2007

Linezolid as antituberculous agent

Linezolide EBA in man : week activity (AJRCCM 2008) MIC M.tuberculosis = 0.5 mg/l (Alcala 2003) Pharmacokinetics (Gee, 2001) peak in serum = 18 mg/l ½ life : 5 hours EBA in man : week activity (AJRCCM 2008)

Linezolide : activity in mice Bacterial load in spleen and lungs after 1 month of treatment in mice inoculated with 6.8 log UFC M.tuberculosis Cynamon AAC 1999 < 2 logs 3 logs 25 mg/kg oxazolidinone 100mg/kg

Linezolide in man 5 MDR TB treated by LZN + thiacetazone + clofazimine (+/- amox-clav) Negativation of respiratory sample after 6 weeks 5-24 months : 3  cured, 1 lost of follow up, 1 on tt after 11 months 4 severe anemias leading to blood transfusions 2 polynevritis 1 pancreatitis Fortun JAC 2005

Linezolide in man 10 MDR TB treated by various regimens + LZN Negativation of respiratory sample 9/10 5 anemias 6 polynevritis Bent von der Lippe J Inf 2005

Diarylquinolines R207910 (TMC207)

R207910 Andries Science 2005 ATP synthase Séquençage complet Janssen (Jonhson & Jonhson) Pharmaceutical Research and Development) Séquençage complet de 2 couples sauvage/mutant résistant (M.tuberculosis, M.smegmatis) : sous-unité c ATP synthase (gène atpE) Andries Science 2005

Diarylquinoline : R207910 (TMC207) Inhibition of ATP synthase H+ H+ H+ F0 Subunit c (atpE) H+ F1 Andries Science 2005 ADP + Pi > ATP Ephraim Racker mitochondria 1961 Size : 9 nm Inhibited by oligomycin

In vitro activity (MIC mg/l) of R207910 against clinical strains of Mycobacterium tuberculosis susceptible 6 0.03-0.12 R rifampicine 1 0.03 R ethambutol 0.01 R pyrazinamide R fluroquinolones 3 0.06-0.12 R isoniazide 7 0.03-0.06 R rifampicine + isoniazide (MDR) 2 Andries Science 2005

R207910 alone in established murine TB infection (2 months) Andries Science 2005 Control Log CFU in lungs Rifampin 10 mg/kg R = rifampin 10 mg/kg H = isoniazid 25 mg/kg Z = pyrazinamide 150 J 25 mg/kg R207910 is more active than rifampicine and as active as rifampicine + isoniazid + pyrazinamide

R207910 combined with 1st line drugs in mice (2 months) H = isoniazid 25 mg/kg R = rifampin 10 mg/kg Z = pyrazinamide 150 mg/kg J = J 25 mg/kg 4 to 5 logs drop in 4 weeks RHJ RJZ JHZ Untreated controls RHZ RHZJ 0 cfu lung ≤ 1 cfu spleen Z H R Andries Science 2005

Relapses 3 months after stopping treatment in mice : impact of R207910 J: R207910 R: rifampicine H : isoniazide Z: pyrazinamide % 2 JRZ + 2 JR Tt standard Veziris AJRCCM 2008

R207910 combined with 2nd line drugs MDR TB in mice Log cfu AEtZ : 3 major drugs for MDR TB + moxiflox M = moxifloxacin A = amikacine Z = pyrazinamide Et = ethionamide + R207910 Lounis AAC 2006

Sterilizing activity in MDR TB (mice) : relapse 3 months after end of treatment % relapses gold standard MDR TB  58% + J gold standard S TB  40% 28% 16% 11% 11% 2RHZ +4RH 2JRZ +2JR 2AEtMZ +4EtM 2JAEtMZ +4JEtM 2JMZ +2JM 2JMZ +4JM 24

drugs, given 1/week in mice (2 months) R207910 combined with other drugs, given 1/week in mice (2 months) Log cfu J : R207910 M : moxifloxacine P : rifapentine Z : pyrazinamide DO J M P JP JPH JPM JPZ Veziris AJRCCM 2008

R207910 (TMC207) in man (Diacon ICAAC 2008) MDR TB South Africa

Nitro-imidazoles PA-824 OPC-67683

Nitro-imidazoles : PA-824 (PathoGenesis Corp Nitro-imidazoles : PA-824 (PathoGenesis Corp. >> global Alliance against TB) MIC on M.tuberculosis : 0.06 - 0.1 mg/L Stover Nature 2000

PA-824 : initial phase in mice log CFU In initial phase PA-824 has a bactericidal activity slightly lower than that of INH Tyagi AAC 2005, Leanerts AAC 2005

PA-824 : continuation phase in mice lung culture + 4 months 6 months 2 RHZ / RH 0/6 2 RHZ / PA-824 In continuation phase, PA-824 has apparently a bactericidal activity comparable to that of RIF + INH Tyagi AAC 2005

PA-824 : relapse experiment in mice (PA en plus de RHZ) (PA remplace INH dans RHZ) Nuermberger AAC 2006 Week Early Bactericidal Activity (EBA) in man

Nitro-imidazoles : OPC-67683 (Otsuka Pharmaceutical, Tokushima) MIC on M.tuberculosis : 0.01 mg/L Matsumoto PLos Medicine 2006

OPC-67683 : activité en monothérapie chez la souris INH RMP Matsumoto PLos Medicine 2006

OPC-67683 : activité en association chez la souris ORZ RHEZ Matsumoto PLos Medicine 2006

Conclusions (1) Moxifloxacin la bonne Fquinolone pour MDR TB , mais : durée AEtMZ ? (6 mois non, 9 mois ?) comment faire sans aminoside (injectable) ou sans éthionamide (40-50% R) ? à ce jour plutôt décevant pour TB sensible Linézolide : pour les cas désespérés (certains XDR) Diarylquinoline (TMC207) : encourageant pour MDR TB et pour TB sensible 1/semaine (à suivre…) Nitroimidazoles PA824 décevant OPC67683 : tout début

Conclusions (2) Le traitement standard 2 RHZE + 4 RH (OMS) a encore de beaux jours pour la tuberculose sensible Le traitement supervisé « facile » (oral et 1 seule administration par semaine) n’est pas pour tout de suite Le traitement des TB-MDR est amélioré (FQ) mais encore long et délicat Le traitement des TB-XDR est très problématique >> ne pas générer de TB-MDR à partir des TB sensibles >> ne pas générer de TB-XDR à partir des TB MDR

>> MDR : resistant to R and H MDR definition (WHO) 2 major antituberculous drugs : Rifampicine (R) Isoniazid (H) >> MDR : resistant to R and H Main antituberculous drugs for MDR : Aminoglycosides Fluoroquinolones (Ethionamide) (Pyrazinamide)

MDR TB (WHO report 2004 ) 424 000 cases/year Primary : 243 000 (3% of new cases) Secondary : 181 000 (19% of previously treated cases) China, India, Russia : 261 000 (62% of total) > 10% MDR : Estonia (17%), Georgia (16%), Azerbaïdjan (15%), Moldavia (15%), Kazakhstan (14%), Ouzbekistan (13%)

TB Extensive Resistance to 2nd line Drugs M. tuberculosis with Extensive Resistance to Second-Line Drugs - Worldwide, 2000-2004 MMWR March 24, 2006 XDR : resistance to isoniazid and rifampin and at least 3 of the 6 main classes of SLDs 17,690 TB isolates : 20% MDR and 2% XDR

Revised Definition XDR-TB October 2006 Resistant to INH and RIF (MDR-TB) and Resistance to amikacin, kanamycin or capreomycin (injectable agents other than streptomycin) Resistance to fluroquinolones

XDR-TB (in % of MDR cases) WHO 4th Report

XDR-TB : key findings 4th report 2008 Representative data available for 39 countries or regions (24 in Europe) Total data for ~ 5.000 MDR TB cases 2002-07 % XDR TB among MDR TB : 0 - 1% in 14/39 (e.g. Canada, UK, France, N.Zealand, Denmark, Poland) 2 - 10% in 15/39 (e.g. Latvia, USA, Sweden, Netherlands, Israel, Australia, Argentina, Romania, Armenia, Georgia, Moldova, Korea) > 10% in 10/39 (33% Ireland, 33% Slovenia, 31 % Japan, 24% Estonia, 20% Czech, 15% H.Kong, 15% Ukraine, 14% Lithuania, 13% Azerbaijan) only 4 countries with 10-20 cases/year : Japan, Estonia, Latvia, Azerbaijan South Africa : non representative data 1.000 cases 2004-07

R207910 et antituberculeux de première ligne R = rifampicine H = isoniazide Z = pyrazinamide J = R207910 Andries, Science 2005 R207910 a une activité équivalente au traitement standard RHZ

R207910 : activité stérilisante % rechutes Rifampicine Isoniazide Pyrazinamide + Diarylquinoline Rifampicine Pyrazinamide + Diarylquinoline Rifampicine Isoniazide Pyrazinamide Sur cet histogramme vous voyez en abscisses le N de mois de trt et en ordnonées le % de souris qui rechutenet 3 mois après l’arrêt du traitement Voyons tout d’anprd le groupe contrôle qui a reçu le trt standard rhz. Ce groupe a eu 17% de rechutes ce ui assez classique dans ce modèle assez pessimiste Les deux groupes recevant la drq avaient une activité équivalent mais en seulement 4 mois que l’on rajoute la drq ou que l’on remplace l’inh par la drq Nous avons donc montré qu’il était possible gace à l’apprt de la drq de réduire la durée du trt de la tb à baciles sensibls de 6 à 4 mois Veziris AJRCCM 2008 la diarylquinoline réduit de 6 à 4 mois la durée du traitement

R207910 in man : EBA Low activity in the 1st week R207910 isoniazide 25 mg/j 100 mg/j 400 mg/j isoniazide rifampicine Low activity in the 1st week

Moxifloxacin-rifapentine in 2/week 4 months treatment in mice Pas de rechute chez la souris traitée 4 mois : 2 semaines RHZ ou RMZ 6 semaines PHZ ou PMZ 2 mois PH ou PM Rosenthal AJRCCM 2006

In vitro activity (MIC mg/l) of R207910 against MOTT M. avium 7 0.01 M. kansasii 1 0.003 M. fortuitum 5 M. abscessus 0.25 M. ulcerans 0.5 M. marinum M. xenopi 0.03 4 Andries Science 2005

New agents active against Mycobacterium tuberculosis MIC mg/l Acivity in mice Linezolide (oxazolidinone) 0.5 moderate* PA 824 (nitroimidazopyrane) 0.1 good** R207910 (diarylquinoline) 0.01 high*** * Cynamon AAC 1999 ** Stover Nature 2000 *** Andries Science 2005

Moxifloxacine in 1/week 6 months TB treatment in mice (P : rifapentine, H : isoniazide) Initial phase 1/day continuation phase 1/week lung culture + 6 months 9 months 2 RHZ + 4 RH 5/7 0/18 0.5 RHZM100 + 5.5 P10HM100 4/15 0.5 RHZM100 + 5.5 P15HM100 2/16 0.5 RHZM400 + 5.5 P10HM400 0/16 0.5 RHZM400 + 5.5 P15HM400 0/13 6 HP15M400 (24 doses) 2/18 *DO : 5.6 log10 Veziris AAC 2005

In vitro activity of R207910 against Mycobacterium tuberculosis Proportion of resistant mutants : 5 x 10 - 7 to 5 x 10 – 8 (# rifampicine) Andries Science 2005

In vitro activity (MIC mg/l) of antituberculous agents against M In vitro activity (MIC mg/l) of antituberculous agents against M.tuberculosis H37RV resistant to R207910 selected in vitro Wild type Mutant BK12 R20791 0.03 4 Isoniazide 0.12 Rifampicine 0.5 Ethambutol 2 Streptomycine 1 Amikacine Moxifloxacin 0.25 Andries Science 2005

Early bactericidal activity (EBA) of moxifloxacin Change in CFU per ml of sputum N day 0 day 2 day 5 EBA log/day INH 6 mg/kg 9 12 3 1 0.21 Moxiflox. 400 mg 8 14 4 0.27 Pletz AAC 2004

Nitro-imidazoles : PA-824 Activation par réduction requière FGD1, une glucose 6-phosphate déhyrogénase dépendante du cofacteur F-420 (coenzyme de réduction) Mutants R = déficients en F-420 (60%) ou en FGD1 (20%) cible inconnue Manjunatha PNAS 2006