VIII. CAN MEDICATION MONITORS HELP PREVENT DRUG RESISTANT DISEASE

Recently, serious concern has been expressed about an alarming increase in multi drug resistant (MDR) and extreme drug resistant (XDR) TB. WHO officials quite properly point out that this problem is a reflection of the weakness of TB management, which should include strict supervision of treatment to minimize the emergence of drug resistance.  (Raviglione and Smith 2007). Does this concern and does this statement imply we should return to the old policy of DOT for all patients?

DOT is often given 2 or 3 times a week (intermittent regimens) at least in the continuation phase of therapy for patients being treated for the first time. A review of intermittent regimens for TB found that they had somewhat higher relapse rates than treatment given daily. (Saltini 2006)  In HIV positive patients rifampin resistance developed in 1.7 to 3.7% of patients who received intermittent DOT (Li et al. 2005; Nettles et al. 2004). The emergence of MDR-TB has been noted in a community based DOT program. (Davies et al. 1997) One study showed that acquired INH drug resistance occurred in 20% of the patients who relapsed after DOT. (Thomas et al. 2005) WHO reports that 14% of patients did not achieve treatment success in 2004 (WHO 2007). While not documented, drug resistance probably occurred in some of these patients.  Furthermore, the difficulty many patients have in complying with DOT motivates some of them to get poor quality treatment from pharmacies or private physicians, which increases the opportunity for drug resistance to emerge. This type of information suggests that a policy of strict DOT for all patients has significant limitations.

However, the new standards (Tuberculosis Coalition for Technical Assistance 2006) which recommend assessing adherence and addressing poor adherence when it occurs may be equally ineffective or less effective in preventing drug resistance, because current means of assessing adherence are frequently inaccurate. If medication monitors were used to determine adherence to daily regimens, the effectiveness of the new standards could probably be greatly improved.  If adequate supportive and remedial measures were taken when poor adherence is found, less drug resistance could emerge than now occurs in communities that attempt but fail to give uninterrupted DOT to all patients.

On the other hand until there is significant positive experience with monitored SAT, daily DOT should be given to patients that are known to have drug resistant disease prior to starting treatment, because if treatment fails there is often no other effective treatment regimen.
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SUMMARY

I. INTRODUCTION

II. THE SUCCESS AND PROBLEMS WITH DOT

III. RELIABLE PATIENTS - A POTENTIAL RESOURCE FOR REDUCING THE ADHERENCE PROBLEM

IV. DETERMINING THE ADHERENCE OF PATIENTS

V. EXPERIENCE WITH SELF ADMINISTERED TREATMENT GIVEN IN MEDICATION MONITORS (MONITORED SAT)

VI. PROPOSED SUPERVISION OF TREATMENT BASED ON MONITORED SAT AND DOT GIVEN SELECTIVELY

VII. USE OF MONITORED SAT TO IMPROVE TREATMENT OUTCOMES AND EXPAND SERVICES IN VARIOUS SETTINGS

VIII. CAN MEDICATION MONITORS HELP PREVENT DRUG RESISTANT DISEASE

IX) USE OF MEDICATION MONITORS WHEN MANAGING HIV/AIDS and HIV/AIDS/TB

X) EXPENSE AND PRACTICALITY OF USING MEDICATION MONITORS

XI. EVALUATION

XII. IN SUM

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