No evidence-based tools exist to enhance precision in selection of patient-specific optimal treatment durations to study in tuberculosis clinical trials.
Develop risk stratification tools that assigns tuberculosis patients into risk groups of unfavorable outcome and informs selection of optimal treatment duration for each patient strata to study in clinical trials.
Publicly-available data from four phase 3 trials, each evaluating treatment duration shortening from 6 to 4 months, were used to develop parametric time-to-event models that describe unfavorable outcomes. Regimen, baseline, and on-treatment characteristics were evaluated as predictors of outcomes. Exact regression coefficients of predictors were used to assign risk groups and predict optimal treatment durations.
The parametric model had an area under the receiver operating characteristic curve of 0.72. A six-item risk score (HIV status, smear grade, sex, cavitary disease status, BMI and month 2 culture status) successfully grouped participants into low (1060/3791,28%), moderate (1740/3791,46%), and high (991/3791,26%) risk, requiring treatment durations of 4, 6 and greater than 6 months, respectively, to reach a target cure rate of 93% when receiving standard-dose rifamycin-containing regimens. With current one-duration-fits-all approaches, high risk groups have 3.7-fold (95%CI: 2.7-5.1) and 2.4-fold (1.9-2.9) higher hazard risk of unfavorable outcome compared to low and moderate groups, respectively. Four-month regimens were noninferior to the standard 6-month regimen in the low risk group.
Our model discrimination was modest but consistent with current models of unfavorable outcomes. Our results showed that stratified medicine approaches is feasible and may achieve high cure rates in all tuberculosis patients. An interactive risk stratification tool is provided to facilitate decision making in the regimen development pathway.