Bedaquiline, pretomanid, linezolid, and moxifloxacin treatment for multi-drug resistant extrapulmonary tuberculosis in Canada: a report

Background: Updated global tuberculosis (TB) guidelines recommend the novel oral 6-month bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) regimen for multidrug-resistant TB (MDR-TB) based on superior efficacy and reduced toxicity demonstrated in clinical trials. These trials were dominated by isolated pulmonary TB; thus, data for BPaLM effectiveness for extrapulmonary tuberculosis (EPTB) remains limited. Methods: We describe the safe and effective use of BPaLM in a patient for the treatment of MDR-TB involving an extrapulmonary site. Results: Bedaquiline and pretomanid were obtained through the Health Canada Special Access Program and from the manufacturers 3 weeks later. The patient with gastrointestinal and subclinical pulmonary TB tolerated the 6 months of BPaLM well with no treatment interruptions. There was sustained microbiological and clinical response at 6 months after treatment completion. Conclusion: Shorter duration, improved effectiveness, and reduced toxicity suggests that BPaLM should be considered when determining the ideal treatment regimen for MDR-TB. A more streamlined process for the procurement of bedaquiline and pretomanid will help minimize treatment initiation delay and overall isolation period. Further research is also needed to clarify longer-term outcomes and optimal dosing of BPaLM for EPTB, especially in more severe forms of disease or with malabsorption concerns.