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A trial on cycloserine in salvage cases of pulmonary tuberculosis
Tubercle, Lond., (1963), 44, 351
A TRIAL ON CYCLOSERINE IN SALVAGE CASES OF P U L M O N A R Y TUBERCULOSIS By R. VISWANATHAN,N. P. GUPTA,P. U. RAO and D. C. RoY Gore Vallabhbhai Pate/C/test Institute, University of De/t/i, Patel Marg, Dehli 6, India
SUMMARY A trial is reported of the efficacy of cycloserine in patients in whom treatment with the primary drugs had failed. Fifty-seven patients were treated, 30 with 250 nag. cycloserine three times daily and 27 with inert tablets. The treatment continued for four months. Throughout this time they also received the anti-tuberculosis chenmtherapy that they were receiving before the trial began. The group having cycloserine showed more radiographic improvement, gained more weight and had a greater reduction of ESR than those not having cycloserine. The sputum, initially positive in all cases, was negative in 56 ~,, after four months-treatment with cycloserine. Toxic effects of the drug were not considered to be important in most cases. Three patients had transient epileptiform fits but were able to continue treatment after a short interval.
A synthetic preparalion of the antibiotic cycloserine was made available to us for clinical trial in tuberculosis. It was decitted to try the drug in 'salvage' cases of pulinonary tuberculosis, patients who were undergoing treatment in the wards of the Silver Jubilee Tuberculosis Hospital, Delhi. Cuckler and others (1955) have shown that cycloserine inhibits human, bovine and avian tubercle bacilli irrespective of their sensitivity to streptomycin, isoniazid or PAS. Welch, Putnam and Randall (1955) observed that cycloserine was less active than other antibiotic compounds and that it had a broad antibacterial spectrum. Nair and others (1955) found that absorption of cycloserine took place rapidly in man and it appeared in the plasma within one hour of oral administration. French physicians have used cycloserine fairly extensively. Bernard & IsraEl (1957) reported the results of cycloserine treatment in 22 males and nine females, all of whom had a positive sputum. After treatment, 16 patients became sputum negative and in six there was considerable radiological improvement. These workers concluded that cycloserine was a useful drug in patients resistant to treatment with streptomycin and isoniazid. Other favourable reports on the use of cycloserine in treatment of tuberculosis have been made by Hein and Barthold (1959), Dumittan (1960), Primer (1960) and Krackhardt (1960). More recently, McDougail (1961) made a preliminary report on clinical trials with cycloserine in three different countries, Greece, Yugoslavia and Turkey. Far advanced cases of pulmonary tuberculosis were studied. All patients had undergone intensive therapy with streptomycin, isoniazid and/or PAS for varying periods. Out of 74 given cycloserine in Athens for a period of four to five months, 52 (72~o) became sputum negative. Sixty (81 ~o) showed increases in weight and in only four cases was there increase of the pulmonary lesions. The general condition of the patients had improved in 65 (88 ~). He concluded that cycloserine in the doses used was a relatively safe form of medication and could be an excellent alternative for patients who have failed to respond to treatment with streptomycin, isoniazid and PAS.
352
TUBERCLE
Material and Methods A double-blind clinical trial was undertaken to determine the usefulness of cycloserine in the so-called 'salvage' cases ot" pulmonary tuberculosis. Only those patients in whom prolonged chemotherapy had not produced any improvement and where the disease was still active with or without deterioration and where surgery was not possible, were included in the trial. All of them had far advanced disease, according to American Thoracic Society classification. The patients were selected from those undergoing treatment as in-patients in the Silver Jubilee Tuberculosis Hospital, Delhi, for varying periods. All had chemotherapy for at least two years. Before admission to the trial, each patient underwent complete re-examination including radiography, blood examination (including erythrocyte sedimentation rate) and sputum culture with sensitivity tests. The radiographs were seen by three of us and reports recorded. All the patients were seen by one of us daily and all the toxic manifestations, progress etc. were recorded. Examinations were repeated every month till the completion of the trial. Sixty-six amber coloured bottles of !he same shape and size were selected and numbered at the bottom. Thirty-three of them were selected at random and filled with the requisite number of tablets of cycloserine. The other 33 were filled with inert tablets. The numbers of the bottles containing cycloserine and placebo were entered on a piece of paper by tile pharmacist and kept in a sealed cover. The patients selected were given one bottle each at random. In this way, it was ensured that neither the patient nor the doctors knew which patient was receiving cycloserine and which an inert preparation. The patient was given the number corresponding to the number entered at the bottom of the bottle. Even at the time of final assessment, we were not aware which patients belonged to the cycloserine series and which to the control series.
Chemotherapy Patients in both the trial and control groups continued tO get whatever chemotherapy they had been receiving previously. All tile patients had had treatment with streptomycin and isoniazid initially followed by PAS and isoniazid. The tablets of cycloserine or the inert substance were just added to the regular therapeutic regime. Treatment was started with one (250 mg.) tablet. On the third day two doses each of 250 mg. was given and on the fifth day three doses (750 mg. daily). The tablets were administered with water after meals.
Duration of Observation All the patients were treated for four months. The final assessments were made at the end of this period.
Bacteriological Examinations A 24-hour specimen of sputum collected in a sterile glass container was treated according to Petroff's method (Soltys, 1952). After treatment with NaOH, the centrifuged deposit was washed three times with distilled water before inoculation on L6wenstein-Jensen medium. Observations were made up to 28 days for growth of acid-fast bacilli. Drug sensitivity tests on the cultures were carried out before and after treatment. Sensitivity to streptomycin, PAS and isoniazid was estimated according to the techniques described by Cruickshank (1962). Cultures of H37RV were used for control purposes. Resistance ratios were calculated in each case. Sensitivity to cycloserine was determined in a similar manner by incorporating the drug in concentrations varying from l0 ,~g to 120 .~g per ml. in the medium. Resistance ratio of two and less were taken as sensitive and ratios of four and above were taken as resistant.
Withdra,,als
Results Only sixty-two patients were available, so four bottles were not used. Five patients left hospital against medical advice within a few weeks of the start of the trial. It was found that three of them were taking cycloserine and two the inert tablets. The remaining 57 patients were available for analysis; 30 had cycloserine and 27 inert tablets.
CYCLOSERINE
353
Deaths One patient in tile cycloserine group died soon after the fourth month, as did three in the control group. Three patients in the control group died during the fourth month. The particulars for these three patients used in the analysis are those obtained at the end of the third month. Comparability of Groups (Table I) The differences between the groups before treatment in regard to age, sex, radiographic severity, ESR, weight and drug resistance were slight. The control group had a higher mean ESR.
Radiographic
Results of Treatment
At the end of tile four months treatment, 17 (57 %) of the 30 in the cycloserine group were classed as 'moderately advanced', compared with only one (4~o) in the control group. There was slight improvement in eight ( 2 7 ~ ) of the cycloserine group and five ( 1 9 ~ ) of the control group. No patients receiving the cycloserine became radiographically worse, compared with eight (29~o) of those receiving the inert tablets. The differences in radiographic change are statistically significant.
ESR In the cycloserine group, the mean ESR fell from 66 to 16 mm. in one hour and in the control group from 86 to 72. The fall in the cycloserine group was almost four times as great as in the control group. (Tile change of ESR in the cycloserine group is highly significant, that in the control group is not significant). TABLE I . - - T H E AGE AND SEX DISTRIBUTION OF THE CYCLO o SERINE AND CONTROL GROUi'S, WITH THE PRE-TREATMENT X-RAY ASSESSMENTS, ESR's AND WEIGHTS AND THE DRUG SENSITIVITIES OF CULTURES OBTAINED BEFORE TREATMENT
Cycloserine ] Control group group I 30
27
16 9 5
13 7 7
21 9
17 10
30
27
ESR Mean
66 ram.
86 ram.
Weight Mean
45 kg.(100 ibs.)
42 kg.(93 lbs.)
29 of 30 28 of 30 28 of 30
23 of 25 20 of 25 21 of 25
Total Age (years) 21-30 31-40 "
o v e r 40 Sex
Men Women Radiographic Far-advanced
Drug resistance Streptomycin isoniazid PAS
354
TUBERCLE
Weight The mean gain of weight in the cvcloserine group was 3.6 kg. (8 lbs.) a statistically significant difference. In the control group the ~ e a n weight remained almost unchanged.
Bacteriological In the cycloserine group, 17 of the 30 patients had a negative sputum culture at the end of the fourth month, compared with two of 27 in the control group. The bacillary count of sputum smears was much reduced in three of the cycloserine group and one of the control group. Ten of the cycloserine group remained positive with no reduction of bacillary count, compared with 24 of the control group. Cycloserine sensitivity tests were done on I 1 cultures after four months treatment with this drug. Six had resistance ratios of four or more.
Toxic Effects Twelve of the 30 patients who had cycloserine complained of giddiness, three had epileptiform fits and two became mentally disturbed; eight complained of dyspnoea. Among the 27 who had inert tablets there were no symptoms attributed to the therapy. The symptoms developed within the first week. The epileptiform fits were alarming; but the symptoms ceased when the drug was withdrawn for two to three days and did not reappear even after the treatment was restarted. The drug was not withdrawn when other symptoms appeared as they were of mild nature. Discussion
The present trial would suggest that cycloserine was effective in patients with far advanced tuberculosis who had not improved with prolonged treatment with the primary anti-tuberculosis drugs. The radiological improvement, increase in weight and fall in sedimentation rate were significant. From the public health point of view, 5 7 ~ sputum conversion in such far advanced cases is an important factor. Even though the patients had not improved during previous treatment it was decided not to discontinue the drugs they were taking, for to do so would amount to stopping all chemotherapy in those who happened to be given the inert tablets. This, however, might have vitiated our results if some of the patients continued to harbour bacilli sensitive to the drugs which were continued. It will, however, be seen that the proportion of sensitive cases in the trial and control groups was practically the same. Hence the results obtained in the cycloserine group can reasonably be attributed to the drug. The side effects of the drug in the present trial were surprisingly few, in spite of the fact that we were warned against its possible toxicity. Except in case of those who developed epileptiform fits, the drug was not stopped. It is possible that even in those which developed fits, the treatment need not have been interrupted, since the other side effects were transient and appeared only at the commencement of the trial It is of interest to note that five out of 1 l strains isolated after treatment with cycloserine continued to remainsensitive to the drug. It is possible that these patients might have becom~ sputum negative if the treatment had been continued for a longer period. REFERENCES BERNARD, E., • ISRAEL, L. (1957). Rev. Tuberc., Paris, 21, t 174. CRUICKSHANK,R. (1962). Mackie and McCartney's Handbook of Bacteriology, edited by R. Cruickshank and others, 10th edition, E. & S. Livingstone, Edinburgh. CUCKLER, A. C., FROST, B. M., MCCLELLANO,L., & SOLOTOROVSKY,M. (1955). Amibiot. and Chemother., 5, 191. DUMITTAS, S. H. (1960). Helv. reed. Acta, 27, 65. HEIN, J., & BERTHOLD, H. (1959). Schweiz. 2".. T, berk., 16, 292. KRACKHARDT, H. (1960). Schweiz. Z. Tuberk., 17, .403. McDOUGALL, J. B. (1961). Schweiz. Z. Tuberk., 18.. 1. NAm, K. G. S., EPSTEIN, i. G., BAROr~',H., & MULINOS,M. G. (1955-56).'Antibiot. Ann., p. 136. PRIMER, V. G. (1960). TuberkArzt., 14, 163. SOLTYS, M. A. (I 952). Tubercle Bacillus and Laboratory Methods in Tuberculosis, E. & S. Livingstone, Edinburgh. WELCH, H., PtrrNAM, L. E., & RANDALL,W. A. (1955). Antibiot. Med., 1, 72.
A TRIAL ON CYCLOSERINE IN SALVAGE CASES OF P U L M O N A R Y TUBERCULOSIS By R. VISWANATHAN,N. P. GUPTA,P. U. RAO and D. C. RoY Gore Vallabhbhai Pate/C/test Institute, University of De/t/i, Patel Marg, Dehli 6, India
SUMMARY A trial is reported of the efficacy of cycloserine in patients in whom treatment with the primary drugs had failed. Fifty-seven patients were treated, 30 with 250 nag. cycloserine three times daily and 27 with inert tablets. The treatment continued for four months. Throughout this time they also received the anti-tuberculosis chenmtherapy that they were receiving before the trial began. The group having cycloserine showed more radiographic improvement, gained more weight and had a greater reduction of ESR than those not having cycloserine. The sputum, initially positive in all cases, was negative in 56 ~,, after four months-treatment with cycloserine. Toxic effects of the drug were not considered to be important in most cases. Three patients had transient epileptiform fits but were able to continue treatment after a short interval.
A synthetic preparalion of the antibiotic cycloserine was made available to us for clinical trial in tuberculosis. It was decitted to try the drug in 'salvage' cases of pulinonary tuberculosis, patients who were undergoing treatment in the wards of the Silver Jubilee Tuberculosis Hospital, Delhi. Cuckler and others (1955) have shown that cycloserine inhibits human, bovine and avian tubercle bacilli irrespective of their sensitivity to streptomycin, isoniazid or PAS. Welch, Putnam and Randall (1955) observed that cycloserine was less active than other antibiotic compounds and that it had a broad antibacterial spectrum. Nair and others (1955) found that absorption of cycloserine took place rapidly in man and it appeared in the plasma within one hour of oral administration. French physicians have used cycloserine fairly extensively. Bernard & IsraEl (1957) reported the results of cycloserine treatment in 22 males and nine females, all of whom had a positive sputum. After treatment, 16 patients became sputum negative and in six there was considerable radiological improvement. These workers concluded that cycloserine was a useful drug in patients resistant to treatment with streptomycin and isoniazid. Other favourable reports on the use of cycloserine in treatment of tuberculosis have been made by Hein and Barthold (1959), Dumittan (1960), Primer (1960) and Krackhardt (1960). More recently, McDougail (1961) made a preliminary report on clinical trials with cycloserine in three different countries, Greece, Yugoslavia and Turkey. Far advanced cases of pulmonary tuberculosis were studied. All patients had undergone intensive therapy with streptomycin, isoniazid and/or PAS for varying periods. Out of 74 given cycloserine in Athens for a period of four to five months, 52 (72~o) became sputum negative. Sixty (81 ~o) showed increases in weight and in only four cases was there increase of the pulmonary lesions. The general condition of the patients had improved in 65 (88 ~). He concluded that cycloserine in the doses used was a relatively safe form of medication and could be an excellent alternative for patients who have failed to respond to treatment with streptomycin, isoniazid and PAS.
352
TUBERCLE
Material and Methods A double-blind clinical trial was undertaken to determine the usefulness of cycloserine in the so-called 'salvage' cases ot" pulmonary tuberculosis. Only those patients in whom prolonged chemotherapy had not produced any improvement and where the disease was still active with or without deterioration and where surgery was not possible, were included in the trial. All of them had far advanced disease, according to American Thoracic Society classification. The patients were selected from those undergoing treatment as in-patients in the Silver Jubilee Tuberculosis Hospital, Delhi, for varying periods. All had chemotherapy for at least two years. Before admission to the trial, each patient underwent complete re-examination including radiography, blood examination (including erythrocyte sedimentation rate) and sputum culture with sensitivity tests. The radiographs were seen by three of us and reports recorded. All the patients were seen by one of us daily and all the toxic manifestations, progress etc. were recorded. Examinations were repeated every month till the completion of the trial. Sixty-six amber coloured bottles of !he same shape and size were selected and numbered at the bottom. Thirty-three of them were selected at random and filled with the requisite number of tablets of cycloserine. The other 33 were filled with inert tablets. The numbers of the bottles containing cycloserine and placebo were entered on a piece of paper by tile pharmacist and kept in a sealed cover. The patients selected were given one bottle each at random. In this way, it was ensured that neither the patient nor the doctors knew which patient was receiving cycloserine and which an inert preparation. The patient was given the number corresponding to the number entered at the bottom of the bottle. Even at the time of final assessment, we were not aware which patients belonged to the cycloserine series and which to the control series.
Chemotherapy Patients in both the trial and control groups continued tO get whatever chemotherapy they had been receiving previously. All tile patients had had treatment with streptomycin and isoniazid initially followed by PAS and isoniazid. The tablets of cycloserine or the inert substance were just added to the regular therapeutic regime. Treatment was started with one (250 mg.) tablet. On the third day two doses each of 250 mg. was given and on the fifth day three doses (750 mg. daily). The tablets were administered with water after meals.
Duration of Observation All the patients were treated for four months. The final assessments were made at the end of this period.
Bacteriological Examinations A 24-hour specimen of sputum collected in a sterile glass container was treated according to Petroff's method (Soltys, 1952). After treatment with NaOH, the centrifuged deposit was washed three times with distilled water before inoculation on L6wenstein-Jensen medium. Observations were made up to 28 days for growth of acid-fast bacilli. Drug sensitivity tests on the cultures were carried out before and after treatment. Sensitivity to streptomycin, PAS and isoniazid was estimated according to the techniques described by Cruickshank (1962). Cultures of H37RV were used for control purposes. Resistance ratios were calculated in each case. Sensitivity to cycloserine was determined in a similar manner by incorporating the drug in concentrations varying from l0 ,~g to 120 .~g per ml. in the medium. Resistance ratio of two and less were taken as sensitive and ratios of four and above were taken as resistant.
Withdra,,als
Results Only sixty-two patients were available, so four bottles were not used. Five patients left hospital against medical advice within a few weeks of the start of the trial. It was found that three of them were taking cycloserine and two the inert tablets. The remaining 57 patients were available for analysis; 30 had cycloserine and 27 inert tablets.
CYCLOSERINE
353
Deaths One patient in tile cycloserine group died soon after the fourth month, as did three in the control group. Three patients in the control group died during the fourth month. The particulars for these three patients used in the analysis are those obtained at the end of the third month. Comparability of Groups (Table I) The differences between the groups before treatment in regard to age, sex, radiographic severity, ESR, weight and drug resistance were slight. The control group had a higher mean ESR.
Radiographic
Results of Treatment
At the end of tile four months treatment, 17 (57 %) of the 30 in the cycloserine group were classed as 'moderately advanced', compared with only one (4~o) in the control group. There was slight improvement in eight ( 2 7 ~ ) of the cycloserine group and five ( 1 9 ~ ) of the control group. No patients receiving the cycloserine became radiographically worse, compared with eight (29~o) of those receiving the inert tablets. The differences in radiographic change are statistically significant.
ESR In the cycloserine group, the mean ESR fell from 66 to 16 mm. in one hour and in the control group from 86 to 72. The fall in the cycloserine group was almost four times as great as in the control group. (Tile change of ESR in the cycloserine group is highly significant, that in the control group is not significant). TABLE I . - - T H E AGE AND SEX DISTRIBUTION OF THE CYCLO o SERINE AND CONTROL GROUi'S, WITH THE PRE-TREATMENT X-RAY ASSESSMENTS, ESR's AND WEIGHTS AND THE DRUG SENSITIVITIES OF CULTURES OBTAINED BEFORE TREATMENT
Cycloserine ] Control group group I 30
27
16 9 5
13 7 7
21 9
17 10
30
27
ESR Mean
66 ram.
86 ram.
Weight Mean
45 kg.(100 ibs.)
42 kg.(93 lbs.)
29 of 30 28 of 30 28 of 30
23 of 25 20 of 25 21 of 25
Total Age (years) 21-30 31-40 "
o v e r 40 Sex
Men Women Radiographic Far-advanced
Drug resistance Streptomycin isoniazid PAS
354
TUBERCLE
Weight The mean gain of weight in the cvcloserine group was 3.6 kg. (8 lbs.) a statistically significant difference. In the control group the ~ e a n weight remained almost unchanged.
Bacteriological In the cycloserine group, 17 of the 30 patients had a negative sputum culture at the end of the fourth month, compared with two of 27 in the control group. The bacillary count of sputum smears was much reduced in three of the cycloserine group and one of the control group. Ten of the cycloserine group remained positive with no reduction of bacillary count, compared with 24 of the control group. Cycloserine sensitivity tests were done on I 1 cultures after four months treatment with this drug. Six had resistance ratios of four or more.
Toxic Effects Twelve of the 30 patients who had cycloserine complained of giddiness, three had epileptiform fits and two became mentally disturbed; eight complained of dyspnoea. Among the 27 who had inert tablets there were no symptoms attributed to the therapy. The symptoms developed within the first week. The epileptiform fits were alarming; but the symptoms ceased when the drug was withdrawn for two to three days and did not reappear even after the treatment was restarted. The drug was not withdrawn when other symptoms appeared as they were of mild nature. Discussion
The present trial would suggest that cycloserine was effective in patients with far advanced tuberculosis who had not improved with prolonged treatment with the primary anti-tuberculosis drugs. The radiological improvement, increase in weight and fall in sedimentation rate were significant. From the public health point of view, 5 7 ~ sputum conversion in such far advanced cases is an important factor. Even though the patients had not improved during previous treatment it was decided not to discontinue the drugs they were taking, for to do so would amount to stopping all chemotherapy in those who happened to be given the inert tablets. This, however, might have vitiated our results if some of the patients continued to harbour bacilli sensitive to the drugs which were continued. It will, however, be seen that the proportion of sensitive cases in the trial and control groups was practically the same. Hence the results obtained in the cycloserine group can reasonably be attributed to the drug. The side effects of the drug in the present trial were surprisingly few, in spite of the fact that we were warned against its possible toxicity. Except in case of those who developed epileptiform fits, the drug was not stopped. It is possible that even in those which developed fits, the treatment need not have been interrupted, since the other side effects were transient and appeared only at the commencement of the trial It is of interest to note that five out of 1 l strains isolated after treatment with cycloserine continued to remainsensitive to the drug. It is possible that these patients might have becom~ sputum negative if the treatment had been continued for a longer period. REFERENCES BERNARD, E., • ISRAEL, L. (1957). Rev. Tuberc., Paris, 21, t 174. CRUICKSHANK,R. (1962). Mackie and McCartney's Handbook of Bacteriology, edited by R. Cruickshank and others, 10th edition, E. & S. Livingstone, Edinburgh. CUCKLER, A. C., FROST, B. M., MCCLELLANO,L., & SOLOTOROVSKY,M. (1955). Amibiot. and Chemother., 5, 191. DUMITTAS, S. H. (1960). Helv. reed. Acta, 27, 65. HEIN, J., & BERTHOLD, H. (1959). Schweiz. 2".. T, berk., 16, 292. KRACKHARDT, H. (1960). Schweiz. Z. Tuberk., 17, .403. McDOUGALL, J. B. (1961). Schweiz. Z. Tuberk., 18.. 1. NAm, K. G. S., EPSTEIN, i. G., BAROr~',H., & MULINOS,M. G. (1955-56).'Antibiot. Ann., p. 136. PRIMER, V. G. (1960). TuberkArzt., 14, 163. SOLTYS, M. A. (I 952). Tubercle Bacillus and Laboratory Methods in Tuberculosis, E. & S. Livingstone, Edinburgh. WELCH, H., PtrrNAM, L. E., & RANDALL,W. A. (1955). Antibiot. Med., 1, 72.