Changes in treatment of TB in the new WHO update 2025.

Read at CDC

These are the changes advised by the WHO in the treatment of tuberculosis.

However these changes are not yet (until April 2026) done in NTEP program in India. So if asked according to NTEP , the already running treatment protocols are used.

1. Drug-Susceptible Pulmonary TB (DS-TB)

The traditional "6-month RIPE" regimen (2 months of HRZE / 4 months of HR) is no longer the sole standard of care for adults and adolescents.

• The Change: Introduction of a 4-month (17-week) regimen.
• The "HPMZ" regimen.
  • Intensive Phase (8 weeks): Isoniazid (H), Rifapentine (P), Moxifloxacin (M), and Pyrazinamide (Z).
  • Continuation Phase (9 weeks): Isoniazid (H), Rifapentine (P), and Moxifloxacin (M).
• Key Shift: Drug Swap: Rifapentine replaces Rifampin; Moxifloxacin replaces Ethambutol.
  • Potency: Rifapentine has a longer half-life and higher potency against M. tuberculosis than rifampin, allowing for the shorter duration.
  • Eligibility: Patients must be 12 years old, 40 kg, and have non-extrapulmonary disease (excluding lymph node TB).

2. Drug-Resistant TB (MDR/RR-TB)

Historically, multidrug-resistant TB (MDR-TB) required 18–24 months of treatment, often involving painful daily injections (aminoglycosides) and significant toxicity.

• The Change: A shift to a 6-month, all-oral, injection-free regimen.
• The Highlight: The BPaLM regimen.
  • Components: Bedaquiline, Pretomanid, Linezolid (600mg), and Moxifloxacin.
• Key Shift:
  • Elimination of Injectables: Amikacin and Kanamycin are no longer first-line.
  • Duration: Reduced by 12–18 months compared to older standards.
  • Pharmacology: Bedaquiline (inhibits mycobacterial ATP synthase) and Pretomanid (inhibits cell wall synthesis) are the "backbone" of this highly effective combination.

3. Pediatric TB (Non-Severe)

The treatment for children has been simplified based on the SHINE trial evidence, recognizing that children often have paucibacillary (low bacterial load) disease.

• The Change: Treatment shortened from 6 months to 4 months.
• The Highlight: The 2HRZ(E)/2HR regimen.
• Key Shift:
  • Duration: Children with non-severe disease (e.g., isolated hilar lymphadenopathy without cavitation) now stop treatment 2 months earlier.
  • Safety: Shorter duration significantly reduces the cumulative risk of drug-induced liver injury (DILI) in pediatric patients.

4. Treatment Delivery: From Clinic to Camera

The delivery of Directly Observed Therapy (DOT) has evolved to accommodate patient autonomy and reduce public health resource strain.

• The Change: Video DOT (vDOT) is now considered an equivalent alternative to in-person DOT.
• The Highlight: Use of synchronous (real-time) or asynchronous (recorded) video for dose verification.
• Key Shift: This removes the "stigma" of health department vehicles visiting homes and allows patients to maintain employment and education while ensuring adherence.

Summary: Then vs. Now