Transplant patients and patients on direct oral anticoagulants are unlikely to be good candidates for either of the rifamycins, given the drug-drug interactions.
In some instances, Rifabutin has been used for TPT because it comes from the family of rifamycins. There is, however, no evidence to support this approach and the drug-drug interactions would have to be carefully considered.
Rifamycin-containing TPT appears safer and at least as effective as INH regimens in preventing TB disease and TB-related death among people living with HIV.57 The HIV population that is on antiretrovirals such as protease inhibitors or nevirapine is also subject to significant drug-drug interactions.58 We suggest that an HIV specialist be involved in deciding the optimal TPT, given its dependence on the antiretroviral regimen. However, efavirenz is safe when used concomitantly with rifampin or rifapentine and dose adjustment is not required.59,60 These drugs are also safe to use with dolutegravir, although the dose of dolutegravir should be doubled when used with rifampin (but not rifapentine).61,62 The combination of rifapentine and raltegravir also appears to be safe.63 Patients receiving antiretrovirals for Hepatitis C can also have significant drug-drug interactions with the rifamycins.
Good practice statements
Transplant candidates should receive latent tuberculosis infection testing and tuberculosis preventive treatment (if testing is positive) prior to transplantation.
In transplant patients receiving latent tuberculosis infection treatment post-transplant, we suggest 9 months of isoniazid (9H) or an alternate non-rifamycin-containing regimen, due to the risk of rejection from altered drug pharmacodynamics with rifamycins.
Switch To: Français