RU2212240C1 - Method for treating the cases of tuberculosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves administering fluoruracyl daily at a dose of 0.1-2.5 mg/kg during at least 2 months in addition to isoniazide treatment. Isoniazide and fluoruracyl are administered concurrently and sequentially or as mixture or intravenously. EFFECT: enhanced effectiveness of treatment; eliminated changes of visceral organs; minimum isoniazide doses. 5 cl, 3 dwg, 5 tbl

Description

 The invention relates to medicine, namely to phthisiology, and can be used in the treatment of tuberculosis.

 Currently, chemotherapy is the main treatment for tuberculosis. The urgent problem of treating tuberculosis is a relatively limited set of effective anti-TB drugs (PTP) and the rapid development of forms of mycobacterium tuberculosis (MBT) resistant to their action. Therefore, there is a constant search for new anti-TB drugs and new methods for treating tuberculosis (RF patents 2080114, A 61 K 31/15, 31/295, 31/455; 2088231, A 61 K 31/505; 2099056, A 61 K 31/505; 2153339 , A 61 K 31/513, A 61 P 31/06; 2165761, A 61 K 31/513, A 61 P 31/06).

 In the standard combination chemotherapy for tuberculosis, isoniazid - isonicotinic acid hydrazide is used as the main and most effective drug. Therefore, the prototype adopted a method of treating tuberculosis with chemotherapy, including isoniazid (MD Mashkovsky. Medicines. - M., Medicine. - 1988. - T.2. - S.315-316). In this method, isoniazid in doses of 6-15 mg / kg per day, usually 10 mg / kg, is used as a drug. In this case, the treatment time is at least 6 months. The use of isoniazid is sometimes limited by the presence of resistant forms of the office for this drug, which reduces the effectiveness of the treatment and increases its duration. The high toxicity of isoniazid is also known, leading to damage to the liver and peripheral nervous system.

 The problem solved by the claimed invention is to increase the effectiveness of the treatment of tuberculosis, the ability to reduce the toxic effect of isoniazid.

 EFFECT: reduction or disappearance of specific pathological changes in the internal organs of animals as a result of treatment; decrease in the number of positive crops of the Office; reduction of treatment time due to accelerated abacillation and regression of tuberculous changes in the lungs; curing isoniazid-resistant tuberculosis; the possibility of using minimal doses of isoniazid.

 To achieve this technical result in a method of treating tuberculosis with chemotherapy including isoniazid, the authors propose additionally to introduce an effective and safe amount of 2,4-dioxo-5-fluoropyrimidine (fluorouracil). The authors suggest the introduction of fluorouracil in a dose of 0.1 ÷ 2.5 mg / kg daily for at least 2 months. Drugs can be administered simultaneously or sequentially. The authors also propose the administration of isoniazid and fluorouracil in the form of a mixture thereof. The introduction of isoniazid and fluorouracil can be carried out intravenously.

The authors experimentally established that treatment of tuberculosis with a combination of isoniazid and fluorouracil is more effective than treatment with one of these drugs, and that the addition of fluorouracil in addition to isoniazid in a dose of 0.1 ÷ 2.5 mg / kg for 2 months is effective and safe. The use of a combination of isoniazid and fluorouracil in the treatment of tuberculosis leads to the fact that, compared with the prototype:
1) after treatment in the organs of animals infected with both laboratory and clinical strains of MBT, specific pathological changes and positive cultures of MBT are reduced or absent; recovery occurs in a shorter time;
2) in patients with an initially progressive course of pulmonary tuberculosis resistant to isoniazid, within the period of 1 to 2 months, the following changes are observed: regression of the clinical symptoms of the disease, abacillation or a decrease in the intensity of the release of MBT, resorption of infiltrative changes, closure of decay cavities in the lungs or delimitation of the process in the form of the formation of fibrosis or dense foci, due to which the treatment time is reduced and recovery occurs;
3) while maintaining the effectiveness of treatment, minimal doses of isoniazid (5 mg / kg) can be used, which reduces its toxic side effect.

The use of fluorouracil in doses less than 0.1 mg / kg did not lead to significant differences from the prototype, that is, it is not effective, and in doses exceeding 2.5 mg / kg, it was accompanied by toxic lesions of the animal organism. Treatment for less than 2 months does not lead to recovery. The introduction of isoniazid and fluorouracil in the form of a mixture is more convenient, and with intravenous administration it is also less traumatic. A mixture of preparations can be prepared, for example, by mixing the appropriate amounts of official solutions of isoniazid and fluorouracil. Acute toxicity of the LD ₅₀ mixture, determined by the Kerber method on 80 white mice, was 267.75 mg / kg, which is less than the LD _{50 of} isoniazid (188.4 mg / kg according to RF patent 2153878, 2000). Intravenous administration of drugs is more effective, since it allows to achieve the maximum concentration of drugs in the blood.

 It is known that fluorouracil belongs to the antimetabolic group of cytostatic agents and is used in the treatment of cancer in daily doses of 10-15 mg / kg in short courses for up to 10 days (MD Mashkovsky. Medicines. - M., - Medicine, 1988. - T 2. - S. 455). The tuberculostatic properties of fluorouracil were first discovered by us in experiments in vitro (RF patent 2153339), and its anti-tuberculosis effect was observed in an in vivo experiment (RF patent 2165761), where it was shown that fluorouracil in doses of 1-2 mg / kg for the anti-tuberculosis effect is not inferior to isoniazid and can be used to treat experimental tuberculosis for a long time. However, in the experiment (RF patent 2165761), it was found that during treatment with only one drug (both isoniazid and fluorouracil), MBT is not eliminated, pathological tuberculous changes in the internal organs are preserved in animals, which indicates the insufficient effectiveness of the treatment with each these drugs separately.

It is known that the combination of several tuberculostatic agents is not always advisable because of the mutual increase in their toxicity, as well as because of the possible incompatibility and the peculiarities of their effect on a biological object. In vitro experiments by the authors showed that isoniazid and fluorouracil are compatible when mixed, while the tuberculostatic activity of the mixture, determined by the method of vertical diffusion, increases sharply. This mixture had a tuberculostatic effect on both laboratory H ₃₇ Rv and the clinical isoniazid-resistant strains of MBT. It was also found that the combined effect of isoniazid and fluorouracil enhances their anti-tuberculosis activity and increases the effectiveness of tuberculosis treatment, which is proved by a chronic experiment in the treatment of tuberculosis caused by laboratory H ₃₇ Rv (example 1) and clinical isoniazid-resistant (example 2) MBT strains in guinea pigs , and in a clinical trial (example 3).

In FIG. 1-3 presents the results of a study of the lungs of a patient with infiltrative tuberculosis:
FIG. 1 - upon admission to the clinic: a) chest x-ray; b) lung tomogram; c) CT of the lung.

 FIG. 2 - after two months of treatment: a) tomogram of the lung; b) CT scan of the lung.

 Figure 3 - x-ray of the chest one month after surgery.

Example 1. Two series of experiments (a and b) were conducted for 2 months each on guinea pigs, males and females, weighing from 200 to 400 g with the formation of homogeneous groups by weight and sex. Each group consisted of 7 animals, a total of 77 animals. The disease was simulated by subcutaneous injection of an MBT culture (laboratory strain H ₃₇ Rv) at a dose of 0.025 mg / kg in a volume of 0.5 ml in the right inguinal region. Treatment began 2 weeks after infection. The animals were divided into groups as follows: control groups 1a and 1b - without treatment; comparison groups 1a and 1b - animals that were daily injected intramuscularly with isoniazid at a dose of 10 mg / kg; experimental groups 1.1-1.7 - animals that received daily intramuscular injection of fluorouracil and isoniazid both in a mixture of drugs, and separately in the doses listed below (Table 1).

 Research methods: intravital assessment of the course of tuberculosis in animals (change in body weight at the end of the experiment - table 2); biochemical and clinical blood tests; pathomorphological studies of internal organs; microbiological examination of organ homogenates for the presence of MBT by culture (table 3).

 The results of the study. In the control groups, more than 50% of the animals fell by the end of the experiment. In the infection zone, there were extensive (up to 3 cm in diameter) ulcers made by necrotic tissue with fistulas to the inguinal lymph nodes. In physical development, animals significantly lagged behind the animals of the remaining groups (Table 2). Blood tests indicated the presence of anemia, an increase in the erythrocyte sedimentation rate (ESR), pronounced changes in the formula in the form of a significant increase in the number of granulocytes and monocytes, and an increase in the level of aspartate aminotransferase. During pathomorphological studies in all animals of the control groups, multiple tuberculous lesions of the internal organs with numerous foci of caseous necrosis were found. Microbiological examination of homogenates of internal organs in all cases resulted in an increase in MBT (Table 3). Thus, in all animals of the control groups, generalized tuberculosis was detected with characteristic laboratory and pathomorphological changes, MBT (+).

 All animals receiving treatment survived. Changes in laboratory parameters in them did not have significant differences and did not go beyond the age norm, with the exception of animals of comparison groups 1 and experimental group 1.6, in which moderate anemia was detected. The introduction of isoniazid and fluorouracil in the form of a mixture or separately did not affect the treatment results.

 At the end of the experiment, animals of comparison groups 1a and 1b, receiving only isoniazid, were superior in weight to animals of control groups 1a and 1b (Table 2). A blood test in the comparison groups revealed low hemoglobin, high ESR and moderate leukopenia with a corresponding decrease in the number of granulocytes and lymphocytes. During a pathomorphological study in the lungs, single, subpleurally located foci of lymphoid infiltration were found, in two cases pneumatic foci. Lymphoid granulomas were found in spleen tissue, and foci of large-pleated sclerosis in intrathoracic and peripheral lymph nodes. Microbiological examination of homogenates of internal organs in all cases resulted in an increase in MBT. Thus, in animals of comparison groups 1 after two months of treatment with MBT (+), signs of the disease remained in the form of anemia and pathomorphological changes in internal organs.

Treatment of tuberculosis with a combination of isoniazid in doses of 5–15 mg / kg and fluorouracil in doses of 0.1–2.5 mg / kg (experimental groups 1.1–1.7) for 2 months was more effective than treatment with isoniazid alone (comparison groups 1a and 1b):
- the number of positive MBT cultures was reduced (3 of 7, group 1.1), there was no MBT growth in homogenates of internal organs (groups 1.2-1.7), see table 3;
- reduced specific pathological changes in internal organs (groups 1.1; 1.2);
- in groups 1.3-1.7 after the treatment, a pathomorphological study revealed only residual changes in the transferred generalized tuberculosis.

 The increase in body weight of animals of both experimental groups and comparison groups (Table 2) significantly exceeded this indicator in animals of control groups, which indicates the effectiveness of the treatment. The decrease in weight gain of animals of group 1.6 compared with other animals of this series treated was probably due to the initial manifestations of the toxic effect of fluorouracil, nevertheless, the treatment was more effective than in comparison group 1 (Table 3).

 Example 2. The experiment was conducted on guinea pigs, males and females, weighing from 300 to 400 g with the formation of homogeneous groups by weight and gender. Each group consisted of 7 animals, a total of 49 animals. The duration of the experiment is three months. The disease was simulated in animals of all groups by subcutaneous injection of an MBT culture (clinical isoniazid-resistant strain isolated from the patient’s sputum) at a dose of 0.025 mg / kg in a volume of 0.5 ml into the right inguinal region. The strain was identified and its drug resistance to isoniazid at a concentration of 100 μg / ml was established. Treatment began 2 weeks after infection. The groups of animals were divided as follows. Control group 2 - without treatment; comparison group 2 - animals that were daily injected intramuscularly with isoniazid at a dose of 10 mg / kg; experimental groups 2.1-2.5 - animals that received daily intramuscular injection of fluorouracil and isoniazid both in a mixture of drugs, and separately in the doses listed below (Table 4).

 Research methods are similar to the 1st example. All animals in all groups survived. The clinical picture of the disease in all cases was erased. Changes in laboratory parameters in the studied animals had no significant differences and did not go beyond the age norm. The results of inoculation of homogenates of internal organs for the detection of MBT in all animals of all groups were negative. The change in animal weight at the end of the experiment is shown in table 5. The introduction of isoniazid and fluorouracil in the form of a mixture of them or separately did not affect the treatment results.

 Animals of the control group 2, not receiving treatment, in terms of weight gain significantly lagged behind the animals of the other groups (table 5). In a pathomorphological study, all of these animals revealed multiple tuberculous lesions of the internal organs with numerous foci of caseous necrosis. Thus, despite the erased clinical picture caused by infection of the pigs with the clinical strain of MBT, generalized tuberculosis was detected in all animals of the control group 2.

 According to the increase in body weight, animals of comparison group 2, which received only isoniazid, did not differ too much from animals of control group 2. During a pathomorphological study in the lungs, they revealed plethora, microatelectases, and multiple lymphoid follicles. In the peripheral and single intrathoracic lymph nodes, caseous-necrotic foci and large-pleated sclerosis were detected. As a result of treatment in these animals, a certain improvement was achieved (compared with animals of control group 2), but at the same time, a slower increase in the mass of animals was noted and pathomorphological changes in the internal organs were preserved.

Adding to the treatment of tuberculosis, including isoniazid, fluorouracil in doses from 0.1 to 2.5 mg / kg increased the effectiveness of the treatment:
- increased weight gain of animals;
- specific pathological changes in internal organs are less pronounced in animals of groups 2.1, 2.2, including the absence of foci of caseous necrosis in the lymph nodes; no other pathological changes were found in animals of other groups, which indicates the recovery of animals.

 As a result, the results of studies conducted on a large number of animals showed a high anti-tuberculosis activity of a combination of isoniazid and fluorouracil, regardless of the nature of the pathogen. The advantages of using this combination of drugs for the treatment of tuberculosis are both in elimination of MBT from the animal organism within up to 2 months from the start of treatment against the background of normalization of homeostasis and in the reduction or absence of specific pathological changes in internal organs, i.e., in curing animals in difference from the results obtained during treatment with one isoniazid (comparison group). The use of a combination of these drugs also compares favorably with the use of fluorouracil alone (RF patent 2165761) both in direct result and in less pronounced side effects. Moreover, it was experimentally shown that the possible doses in addition to the isoniazid of the introduced fluorouracil can vary within a fairly wide range (from 0.1 to 2.5 mg / kg of the animal’s weight) and do not lead to complications with prolonged use.

 Example 3. A clinical trial of the anti-tuberculosis effect of a combination of isoniazid (at a dose of 10 mg / kg) and fluorouracil (at a dose of 1 ÷ 1.5 mg / kg) was performed on 4 patients with progressive infiltrative pulmonary tuberculosis in the decay phase. The extent of the lesion in two cases was limited to one lobe of the lung. Two other patients had foci of seeding on the opposite side. In all cases, the resistance of the office to two or more major anti-TB drugs has been proven. The duration of combination chemotherapy in patients before admission to the clinic ranged from 12 to 14 months. In the clinic, the patient continued chemotherapy with the mandatory appointment of isoniazid, which was administered daily intravenously at a dose of 10 mg / kg. In addition, fluorouracil was prescribed in a dose of 1 ÷ 1.5 mg / kg intravenously daily for up to 3 months. Fluorouracil was administered both in admixture with isoniazid and separately. Assessment of the condition of patients was carried out on the basis of changes in the clinical picture of the disease and indicators of homeostasis, the dynamics of the x-ray picture and the timing of the cessation of bacterial excretion.

 As a result of a comprehensive anti-tuberculosis therapy, including isoniazid with the addition of fluorouracil, all patients observed a positive process dynamics, which was expressed in the rapid, up to 2-3 weeks, relief of intoxication symptoms and normalization of blood counts. A month after the start of treatment, all patients experienced a regression of radiological changes in the form of resorption of infiltrates, reduction in size or closure of decay cavities, complete or partial resorption of foci of seeding. In all cases, abacillation was achieved within up to 2 months.

 Two patients were operated on 2 months after the start of treatment - lobectomy was performed. In both cases, pulmonary tissue fibrosis was detected in the surgical material within the resected areas. Postoperative therapy included only isoniazid and fluorouracil and lasted for one month, after which the patients were discharged under the supervision of a TB doctor. A follow-up examination after 12 months showed no signs of tuberculosis reactivation in these patients.

 In two other cases, treatment was limited to the chemotherapy described above. Three months after the start of treatment in patients with x-ray examination in the lungs at the site of the existing decay cavities, cicatricial changes were detected with complete resorption of the infiltration. During the follow-up examination of these patients after 6 and 12 months, new pathological changes in the lungs were not found in them.

Clinical example Patient P., born in 1972, was admitted with a diagnosis of progressive infiltrative tuberculosis of the upper lobe of the left lung in the phase of decay and seeding within the lobe with damage to the draining bronchus. Office (+). Prior to admission, she received standard multicomponent anti-tuberculosis therapy in a hospital setting for 12 months from the date of detection of the disease. The stability of the office was revealed: S (10), H (5), R (50), E (5). Upon receipt, the general condition is satisfactory. Signs of intoxication are moderately expressed in the form of weight loss (10 kg), subfebrile condition, anemia (Нb 107 g / l), leukocytosis (7.35 • 10 ⁹ / l). On the chest x-ray (Fig. 1a), lung tomogram (Fig. 1b) and CT of the lung (Fig. 1c), the apical pleura thickening is determined on the left, in S _1-2 there is an infiltrative focus measuring 3.5 by 3 cm with strands in surrounding tissue with expanded drainage bronchus. In the infiltrate there is a cavity with clear internal contours. Within the upper lobe, foci of seeding without decay. Right lung unchanged.

 Within 2 months, a comprehensive anti-tuberculosis therapy was carried out, including ethambutol (15 mg / kg), pyrazinamide (15 mg / kg) and daily intravenous administration of a mixture of official solutions of isoniazid (10 mg / kg) and fluorouracil (1.5 mg / kg ) As a result of the treatment, the patient's condition improved. I gained 12 kg in weight. The temperature and laboratory parameters of blood returned to normal, bacterial excretion was stopped. During the control x-ray examination (Fig. 2), a decrease in the size of the infiltrative focus to 2 cm, an increase in the number of strands in the surrounding tissue was found. The decay cavity with a diameter of up to 9 mm, its contours are even. The density of the main focus is +26 +36 N. Within 1-2 segments and in axillary subsegmentes, foci of seeding are preserved without decay, with clear contours. The patient had an upper lobectomy on the left.

 Morphological histological examination of the distal lobe of the lung subpleurally revealed in the apical region 1 cavity of 0.5 cm, surrounded by a thick layer of dense whitish tissue, from which heavy scars extend, and in the respiratory tissue, small dirty yellow foci within the apical segment. The histological conclusion: a fibrosing cavity against the background of tuberculous infiltration in the phase of delimitation and the formation of inactive foci.

 The postoperative period was uneventful. Treatment was continued with isoniazid (10 mg / kg) and fluorouracil (1.5 mg / kg) for one month. When x-ray control a month after surgery, pathological changes in the lungs are not determined, there is a mechanical suture of the left lung after upper lobectomy (figure 3). After 12 months, no signs of tuberculosis reactivation were detected.

 Thus, clinical and experimental studies have confirmed the high efficiency of the combined use of isoniazid and fluorouracil in the treatment of progressive destructive multiresistant tuberculosis.

Claims (5)

 1. A method of treating tuberculosis with chemotherapy, including isoniazid, characterized in that it is additionally administered a safe and effective amount of 2,4-dioxo-5-fluoropyrimidine (fluorouracil).  2. The method according to p. 1, characterized in that the fluorouracil is administered daily at a dose of 0.1-2.5 mg / kg for at least 2 months.  3. The method according to p. 1, characterized in that isoniazid and fluorouracil are administered simultaneously or sequentially.  4. The method according to p. 1 or 2, characterized in that isoniazid and fluorouracil are administered as a mixture thereof.  5. The method according to any one of paragraphs. 1-4, characterized in that isoniazid and fluorouracil are administered intravenously.

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