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Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 130-131

Anemia related to linezolid-based combination regimen in drug-resistant tuberculosis

Department of Clinical Pharmacy, Study Program of Pharmacy, Hang Tuah University, Surabaya, Indonesia

Date of Submission15-Nov-2021
Date of Decision25-Nov-2021
Date of Acceptance09-Dec-2021
Date of Web Publication12-Mar-2022

Correspondence Address:
Oki Nugraha Putra
M.Farm.Klin, Arief Rahman Hakim 150, Surabaya, East Java
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmy.ijmy_231_21

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How to cite this article:
Putra ON, Nur Hidayatullah AY. Anemia related to linezolid-based combination regimen in drug-resistant tuberculosis. Int J Mycobacteriol 2022;11:130-1

How to cite this URL:
Putra ON, Nur Hidayatullah AY. Anemia related to linezolid-based combination regimen in drug-resistant tuberculosis. Int J Mycobacteriol [serial online] 2022 [cited 2022 May 21];11:130-1. Available from: https://www.ijmyco.org/text.asp?2022/11/1/130/339509

Dear Editor,

We appreciate a recent study conducted by Dayyab et al. published in the International Journal of Mycobacteriology reported the safety and efficacy of linezolid-based combination therapy for patients with resistant tuberculosis (TB) in Nigeria.[1] World Health Organization has included linezolid, levofloxacin or moxifloxacin, and bedaquiline as class A for long-term treatment of resistant TB as an individualized regimen.[2] If there are no contraindications, these drugs are strongly recommended to be included in the treatment for resistant TB. One of the main problems in treating resistant TB is severe side effects that can be a risk factor in discontinuation of therapy compared to sensitive TB. One of the severe side effects of linezolid is myelosuppression and peripheral neuropathy. The study by Dayyab et al. stated that 13 of 37 (35.14%) cases of severe side effects were anemia related to linezolid.[1]

Furthermore, there were more significant cases of anemia in patients who discontinued linezolid (62.50%) than those who did not (22.58%). Severe anemia (Hb <8 g/dl) is a life-threatening that must be addressed immediately. If patients intolerant to linezolid due to severe side effects, we recommend changing linezolid to one of the medicines from Class C, such as ethambutol or delamanid. Furthermore, supplementation of iron or folic acid during linezolid therapy is recommended to prevent anemia. A recent study in Indonesia by Pratama et al. stated that 27 of 93 (29.03%) multi-drug resitant-TB (MDR-TB) patients had anemia ranging from mild to life-threatening with an average onset of anemia of 93 days. The linezolid doses of more than 11 mg/kg BW/day or patients <54 kg are risk factors for anemia.[3]

A study by Tang et al. stated that hematological disorders such as anemia, thrombocytopenia, and leukopenia occurred between 2 weeks and 2 months after the administration of linezolid.[4] Another study by Olayanju et al. stated that extended drug resistant-TB patients with HIV had a significant effect in discontinuing linezolid due to anemia and peripheral neuropathy.[5] One of the antiretroviral therapies, such as zidovudine induces anemia. It indicates that resistant TB with HIV using zidovudine must be periodically monitored for Hb levels.[6] Linezolid-associated anemia is dose-dependent. The dose of linezolid for the management of MDR-TB is 600 mg/day. A meta-analysis study by Miiliard et al. stated that a dose of linezolid 300 mg every 12 h has the same effect as 600 mg every 24 h with a lower risk of side effects.[7]

In conclusion, although linezolid-based combination therapy under programmatic conditions is associated with favorable outcomes, the adverse effects must be closely monitored that may warrant interruption of the drug, especially in the early 2 months. Resistant TB patients who use linezolid-based regimens, especially in HIV with TB, those who use immunosuppressant drugs for autoimmune disease, and had a history of recurrent anemia should regularly monitor their Hb levels and take appropriate steps to treat the adverse effects.

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There are no conflicts of interest.

  References Top

Dayyab FM, Iliyasu G, Ahmad BG, Habib AG. Early safety and efficacy of linezolid-based combination therapy among patients with drug-resistant tuberculosis in north-western Nigeria. Int J Mycobacteriol 2021;10:129-35.  Back to cited text no. 1
  [Full text]  
World Health Organization. WHO consolidated guidelines on tuberculosis. Module 4: Treatment - Drug-resistant tuberculosis treatment. 2020.  Back to cited text no. 2
Pratama NY, Zulkarnain BS, Soedarsono S, Fatmawati U. Hematological side effect analysis of linezolid in MDR-TB patients with individual therapy. J Basic Clin Physiol Pharmacol 2021;32:777-81.  Back to cited text no. 3
Tang S, Yao L, Hao X, Zhang X, Liu G, Liu X, et al. Efficacy, safety and tolerability of linezolid for the treatment of XDR-TB: A study in China. Eur Respir J 2015;45:161-70.  Back to cited text no. 4
Olayanju O, Esmail A, Limberis J, Gina P, Dheda K. Linezolid interruption in patients with fluoroquinolone-resistant tuberculosis receiving a bedaquiline-based treatment regimen. Int J Infect Dis 2019;85:74-9.  Back to cited text no. 5
Ikunaiye NY, Denue BA, Aina BA, Aderemi-Williams R, Rawizza HE. Incidence of anaemia among HIV-infected patients treated with zidovudine-containing antiretroviral therapy in Northeastern Nigeria. Ann Ib Postgrad Med 2018;16:115-24.  Back to cited text no. 6
Millard J, Pertinez H, Bonnett L, Hodel EM, Dartois V, Johnson JL, et al. Linezolid pharmacokinetics in MDR-TB: A systematic review, meta-analysis and Monte Carlo simulation. J Antimicrob Chemother 2018;73:1755-62.  Back to cited text no. 7


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