Cargando…
Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials
Rationale: No evidence-based tools exist to enhance precision in the selection of patient-specific optimal treatment durations to study in tuberculosis clinical trials. Objectives: To develop risk stratification tools that assign patients with tuberculosis into risk groups of unfavorable outcome and...
Autores principales: | , , , |
---|---|
Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
American Thoracic Society
2021
|
Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8663006/ https://www.ncbi.nlm.nih.gov/pubmed/34346856 http://dx.doi.org/10.1164/rccm.202101-0117OC |
_version_ | 1784613553067524096 |
---|---|
author | Imperial, Marjorie Z. Phillips, Patrick P. J. Nahid, Payam Savic, Radojka M. |
author_facet | Imperial, Marjorie Z. Phillips, Patrick P. J. Nahid, Payam Savic, Radojka M. |
author_sort | Imperial, Marjorie Z. |
collection | PubMed |
description | Rationale: No evidence-based tools exist to enhance precision in the selection of patient-specific optimal treatment durations to study in tuberculosis clinical trials. Objectives: To develop risk stratification tools that assign patients with tuberculosis into risk groups of unfavorable outcome and inform selection of optimal treatment duration for each patient strata to study in clinical trials. Methods: 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. Measurements and Main Results: 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, body mass index, and Month 2 culture status) successfully grouped participants into low (1,060/3,791; 28%), moderate (1,740/3,791; 46%), and high (991/3,791; 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 a 3.7-fold (95% confidence interval, 2.7–5.1) and 2.4-fold (1.9–2.9) higher hazard risk of unfavorable outcomes compared with low- and moderate-risk groups, respectively. Four-month regimens were noninferior to the standard 6-month regimen in the low-risk group. Conclusions: Our model discrimination was modest but consistent with current models of unfavorable outcomes. Our results showed that stratified medicine approaches are feasible and may achieve high cure rates in all patients with tuberculosis. An interactive risk stratification tool is provided to facilitate decision-making in the regimen development pathway. |
format | Online Article Text |
id | pubmed-8663006 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | American Thoracic Society |
record_format | MEDLINE/PubMed |
spelling | pubmed-86630062021-12-10 Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials Imperial, Marjorie Z. Phillips, Patrick P. J. Nahid, Payam Savic, Radojka M. Am J Respir Crit Care Med Original Articles Rationale: No evidence-based tools exist to enhance precision in the selection of patient-specific optimal treatment durations to study in tuberculosis clinical trials. Objectives: To develop risk stratification tools that assign patients with tuberculosis into risk groups of unfavorable outcome and inform selection of optimal treatment duration for each patient strata to study in clinical trials. Methods: 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. Measurements and Main Results: 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, body mass index, and Month 2 culture status) successfully grouped participants into low (1,060/3,791; 28%), moderate (1,740/3,791; 46%), and high (991/3,791; 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 a 3.7-fold (95% confidence interval, 2.7–5.1) and 2.4-fold (1.9–2.9) higher hazard risk of unfavorable outcomes compared with low- and moderate-risk groups, respectively. Four-month regimens were noninferior to the standard 6-month regimen in the low-risk group. Conclusions: Our model discrimination was modest but consistent with current models of unfavorable outcomes. Our results showed that stratified medicine approaches are feasible and may achieve high cure rates in all patients with tuberculosis. An interactive risk stratification tool is provided to facilitate decision-making in the regimen development pathway. American Thoracic Society 2021-03-30 /pmc/articles/PMC8663006/ /pubmed/34346856 http://dx.doi.org/10.1164/rccm.202101-0117OC Text en Copyright © 2021 by the American Thoracic Society https://creativecommons.org/licenses/by-nc-nd/4.0/This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (https://creativecommons.org/licenses/by-nc-nd/4.0/) . For commercial usage and reprints, please e-mail Diane Gern. |
spellingShingle | Original Articles Imperial, Marjorie Z. Phillips, Patrick P. J. Nahid, Payam Savic, Radojka M. Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials |
title | Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials |
title_full | Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials |
title_fullStr | Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials |
title_full_unstemmed | Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials |
title_short | Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials |
title_sort | precision-enhancing risk stratification tools for selecting optimal treatment durations in tuberculosis clinical trials |
topic | Original Articles |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8663006/ https://www.ncbi.nlm.nih.gov/pubmed/34346856 http://dx.doi.org/10.1164/rccm.202101-0117OC |
work_keys_str_mv | AT imperialmarjoriez precisionenhancingriskstratificationtoolsforselectingoptimaltreatmentdurationsintuberculosisclinicaltrials AT phillipspatrickpj precisionenhancingriskstratificationtoolsforselectingoptimaltreatmentdurationsintuberculosisclinicaltrials AT nahidpayam precisionenhancingriskstratificationtoolsforselectingoptimaltreatmentdurationsintuberculosisclinicaltrials AT savicradojkam precisionenhancingriskstratificationtoolsforselectingoptimaltreatmentdurationsintuberculosisclinicaltrials |