Treat NTM using guideline-based care

Treatment success may be possible1

The decision of how to treat NTM must take into consideration all patient factors, including comorbidities, disease severity and progression, and NTM species and subspecies.2-6

  • The ATS/IDSA Statement recommends treating MAC with a multidrug regimen: macrolide (clarithromycin, azithromycin) + rifamycin (rifabutin, rifampin) + ethambutol, dependent on disease severity and how the disease initially presents2
  • The goals of therapy—as defined by the ATS/IDSA Statement—are sustained culture conversion, improved symptoms, and achieved radiologic improvement2

A delay in treating NTM with ATS/IDSA Statement–recommended therapy could lead to severe consequences7-10

Even mild NTM may be a significant risk factor for accelerated decline in lung function.7,10

  • In a study of 40 NTM patients who did not receive treatment due to minimal symptoms, 97.5% experienced radiographic disease progression over an average of 6 years10

Knowing the common presentations of NTM can help you identify the right treatment path2:

  • The slower progressing form of NTM lung disease2
  • Presents with bilateral multilobar bronchiectasis, especially in the middle and lower lung fields11
  • ATS/IDSA Statement recommends a regimen that includes a macrolide, ethambutol, and rifampin administered 3 times per week2
  • The rapidly progressing form of NTM2
  • Can lead to extensive cavitary lung damage—typically in the upper lobe—and leads to respiratory failure within a few years2,11,12
  • ATS/IDSA Statement recommends a regimen that includes a macrolide, ethambutol, and rifampin administered daily. Intravenous aminoglycosides may also be necessary2

Using ATS/IDSA Statement–recommended therapy1,2,11

The decision of when and how to treat NTM lung disease patients using the ATS/IDSA Statement recommendations must take into consideration patient comorbidities, disease severity and progression, NTM species and subspecies, and patient willingness/readiness to initiate therapy.2-6,13

The ATS/IDSA Statement from 2007 is the current standard for managing and treating NTM lung disease.2

Download the ATS/IDSA Statement Reference Guide

If patients are compliant and well-monitored, they may achieve treatment success.1

ATS/IDSA Statement–recommended treatment can be challenging. In a survey of physicians, only 13% of prescribed treatment regimens met the ATS/IDSA Statement recommendations.1,11

Effective disease management commonly requires the use of adjunctive therapies, like airway clearance techniques.2,14

Airway clearance techniques in addition to treatment may help improve NTM patients’ symptoms.2,14,15 Clearance techniques should be personalized for each patient, depending on the comprehensive care needed, taking into account other lung comorbidities and disease severity.15

Some effective airway clearance techniques include2,14,16:

  • Exercise and physical activity
  • Manual techniques (eg, chest percussion or compressions)
  • Postural drainage
  • Inhalation therapy (eg, humidification and mucoactive agents)

Techniques, such as autogenic drainage, oscillating positive expiratory pressure devices, and high-frequency chest compression devices are recommended for patients with significant mucus production and clearance issues.2

The ATS/IDSA Statement recommends*

Assessing all patient factors2
  • Patient comorbidities3
  • Disease severity and progression4,5
  • NTM species and subspecies2,6
Treating with a multidrug regimen2
MAC
  • Macrolide (clarithromycin, azithromycin) + rifamycin (rifabutin, rifampin) + ethambutol, dependent on disease severity and how the disease initially presents2
  • Should be continued until culture conversion is achieved and sustained for 12 months2
Mycobacterium kansasii
  • Daily isoniazid + rifamycin (rifabutin, rifampin) + ethambutol2
  • Should be continued until culture conversion is achieved and sustained for 12 months2
Mycobacterium abscessus
  • There are no drug regimens of proven or predictable efficacy for treatment2

The ATS/IDSA-recommended treatment path for 
MAC varies by presentation2

MacrolideClarithromycin 1000 mg TIW or azithromycin 500–600 mg TIW
Ethambutol25 mg/kg TIW
RifamycinRifampin 600 mg TIW
IV AminoglycosideNone

MacrolideClarithromycin 500–1000 mg/d or azithromycin 250–300 mg/d
Ethambutol15 mg/kg/d
RifamycinRifampin 450–600 mg/d
IV AminoglycosideStreptomycin or amikacin§ or none

MacrolideClarithromycin 500–1000 mg/d or azithromycin 250–300 mg/d
Ethambutol15 mg/kg/d
RifamycinRifabutin 150–300 mg/d or rifampin 450–600 mg/d
IV AminoglycosideStreptomycin or amikacin§

Isoniazid300 mg/d
Ethambutol25 mg/kg/d for first 2 months, then 15 mg/kg/d
RifamycinRifampin 600 mg/d
IV AminoglycosideStreptomycin for the first 3–6 months

Not recommended for severe or previously treated disease.

Lower dose for weight <50 kg.

§Please refer to the ATS/IDSA Statement for dosing recommendation.

IV=intravenous; TIW=three times weekly.

Susceptibility test recommendations from the ATS/IDSA Statement vary by species. Rapid species and subspecies identification is paramount in order to implement the right treatment regimen.2,17

  • For MAC isolates: Clarithromycin is the only drug for which susceptibility testing is recommended. There has been no established correlation between in vitro susceptibility results for MAC and clinical response outside of macrolides. Rifampin and ethambutol response may not be reliably predicted with current susceptibility methods2
  • For M abscessus isolates: Rapidly growing mycobacterial isolates require susceptibility testing for identification and treatment with amikacin, doxycycline, fluorinated quinolones, a sulfonamide or trimethoprim-sulfamethoxazole, cefoxitin, clarithromycin, and linezolid2
  • For M kansasii isolates: Routine susceptibility testing is recommended for rifampin only2

FREQUENT MONITORING

Managing NTM can be a lengthy and difficult process. Frequent monitoring can help physicians deal with challenges that may occur during ATS/IDSA Statement–recommended therapy.1

  • Review the medication list of NTM patients receiving treatment, and monitor potential interactions throughout the treatment period11
  • Side effects and intolerance can be common with multidrug NTM lung disease regimens. The ATS/IDSA Statement recommends monitoring for adverse drug reactions routinely or at repeat intervals2,18
  • Frequent monitoring can help alert you when treatment needs to be modified or discontinued. The ATS/IDSA Statement recognizes that some medications may need to be introduced gradually at 1 to 2 week intervals so appropriate evaluations of tolerance can be performed2,11,18

  • For patients who do not respond well to the initial ATS/IDSA Statement–recommended therapy, additional drug regimens may be required2,19
  • In order to reduce a patient’s susceptibility to relapse or reinfection, it’s important to monitor any host susceptibility factors and environmental exposure to MAC2,19
    • Patients who initially have sputum conversion, but develop positive cultures after discontinuing therapy, are commonly reinfected by new NTM isolates2
    • Patients who discontinue treatment after fewer than 10 months of negative cultures, and then experience multiple positive cultures, are likely to have experienced a relapse2

The diagnosis and treatment strategies for pulmonary infections caused by NTM are summarized in the Statement by the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA). For the official ATS/IDSA Statement, please visit http://www.thoracic.org/statements/resources/mtpi/nontuberculous-mycobacterial-diseases.pdf.

The ATS/IDSA Statement was published in 2007 and is currently in revision.

*Adapted with permission from the American Thoracic Society. Copyright © 2015 American Thoracic Society. Griffith DE, et al; ATS Mycobacterial Diseases Subcommittee. Am J Respir Crit Care Med. 2007;175(4):367-416. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.

NTM and your practice

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What is your definition of success when treating your NTM patients? (Check all that apply)

 
 
 
 

Stay informed with updates about the latest research in NTM

The goal of treatment starts with identifying your patients’ needs2

The objectives of therapy vary for each patient depending on the clinical presentation and patient needs. For some, both microbiologic and clinical improvement are attainable; for others, suppressive treatment strategies are appropriate to slow progression of NTM infection and improve symptoms.2

The ATS/IDSA Statement defines treatment success as sustained culture conversion, improved symptoms, and achieved radiologic improvement.2

For treatment monitoring, the ATS/IDSA Statement recommends2:

  • Close monitoring by obtaining monthly cultures of sputum
  • Within 3 to 6 months, patients should show clinical improvement
  • Within 12 months, patient sputum culture should convert to negative
  • Microbiologic endpoint of treatment is 12 months of sustained negative cultures

Why culture conversion matters

Culture conversion has been shown to be predictive of symptomatic and radiographic improvement, reinforcing the need for early treatment to reduce disease progression.20,21

  • In a cohort study of 180 patients, converters experienced significant symptomatic improvement in the majority of symptoms. This includes a greater percentage of nonconverters (36%) who presented with hemoptysis (P=0.04)21
  • In that same study, converters also experienced significantly greater radiologic improvement (P<0.0001) in both CT scans and routine chest radiographs21

Treatment success involves a multidisciplinary approach

Due to the complexities of NTM diagnosis and treatment, a multidisciplinary approach involving specialists—like pulmonologists, ID specialists, radiologists, microbiologists, and pharmacists—who have experience managing the disease is important for best quality of care.11,22,23

Once culture conversion is achieved, guidelines recommend treating patients for an additional 12 months2,12