Pharmacokinetics of First-Line Antituberculosis Drugs Using WHO Revised Dosage in ChildrenWith Tuberculosis With and Without HIV Coinfection

Background. Pharmacokinetic data on the first-line antituberculosis drugs using the World Health Organization (WHO) revised dosages for children are limited. We investigated the pharmacokinetics of these drugs in children who were mostly treated with revised dosages. Methods. Children with tuberculosis on first-line therapy for at least 4 weeks had blood samples collected at predose, 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography mass spectrometry methods, and pharmacokinetic parameters were calculated using noncompartmental analysis. Factors associated with plasma peak concentration (C-max) and the area under the time-concentration curve 0-8 hours (AUC(0-8h)) of each drug was examined using univariate and multivariate analysis. Results. Of the 62 children, 32 (51.6%) were male, 29 (46.8%) were younger than 5 years old, and 28 (45.2%) had human immunodeficiency virus (HIV) coinfection. Three patients had undetectable pyrazinamide and ethambutol concentrations. The median (interquartile range) AUC(0-8h) for isoniazid was 17.7 (10.2-23.4) mu g center dot h mL(-1), rifampin was 26.0 (15.3-36.1) mu g center dot h mL(-1), pyrazinamide was 144.6 (111.5-201.2) mu g center dot h mL(-1), and ethambutol was 6.7 (3.8-10.4) mu g center dot h mL(-1). Of the children who received recommended weight-band dosages, 44/51 (86.3%), 46/56 (82.1%), 27/56 (48.2%), and 21/51 (41.2%) achieved target C-max for isoniazid, pyrazinamide, ethambutol, and rifampin, respectively. In multivariate analysis, age, sex, HIV coinfection status, and drug dosage in milligrams per kilogram were associated with the drugs' plasma drug C-max or AUC(0-8h). Conclusions. The revised dosages appeared to be adequate for isoniazid and pyrazinamide, but not for rifampin or ethambutol in this population. Higher dosages of rifampin and ethambutol than currently recommended may be required in most children.