One of the key benefits of the new guidelines is reducing treatment discontinuation, as the long duration of previous TB therapies often led patients to stop before completing the full course.
Published Sep 16, 2025 | 7:00 AM ⚊ Updated Sep 16, 2025 | 7:00 AM
India has one of the highest burdens of TB.
Synopsis: Patients with tuberculosis, including children and those with drug-resistant strains, can now complete treatment in a shorter, fully oral course, reducing side effects and improving adherence. The new regimens, developed by leading international respiratory and infectious disease bodies, replace traditional six-month therapies with shorter course. Experts say the shorter treatments could ease patient burdens, lower programme costs, and increase cure rates, but caution that their real-world impact in high-burden countries such as India has yet to be fully assessed.
Patients with tuberculosis (TB), including children and those with drug-resistant forms, can now complete treatment in a shorter, fully oral course under new international guidelines.
The recommendations, developed by leading international respiratory and infectious disease bodies, replace traditional six-month therapies with simpler, more effective regimens designed to improve adherence, reduce side effects, and curb the global burden of TB, which remains one of the world’s deadliest infectious diseases.
Developed using rigorous evidence-based frameworks called GRADE and GRADE-ADOLOPMENT, the guidelines draw on large clinical trial data and systematic reviews.
A joint panel representing multiple disciplines oversaw the process to ensure careful, evidence-based recommendations. They are intended for settings with advanced diagnostics and aim to make TB treatment shorter, safer, fully oral, and less reliant on older, more toxic drugs.
The new recommendations, developed by the American Thoracic Society, the US Centers for Disease Control and Prevention, the European Respiratory Society, and the Infectious Diseases Society of America, differentiate between adults, children, and drug-resistant cases.
For people with drug-susceptible pulmonary TB, a new four-month regimen is now advised, replacing the six-month course.
“Children with non-severe TB can also be treated with a shorter four-month course, making therapy easier for families while still ensuring effectiveness,” the guidelines note. Children’s doses are based on weight to ensure safe and effective treatment.
Adults with drug-susceptible TB are recommended a combination of isoniazid, rifapentine, pyrazinamide, and moxifloxacin. Children begin with an eight-week intensive phase using isoniazid, rifampin, pyrazinamide, and sometimes ethambutol, followed by a continuation phase with isoniazid and rifampin alone.
For drug-resistant TB, including rifampin- and fluoroquinolone-resistant cases, the guidelines emphasise new combinations built around bedaquiline, which blocks bacterial energy production; pretomanid, effective against both active and dormant bacteria; and linezolid, a strong antibiotic for resistant infections.
This regimen, known as BPaL, lasts 26 weeks. Where fluoroquinolones remain effective, moxifloxacin is added to form the BPaLM regimen.
“These all-oral regimens are structured to improve adherence and outcomes. Patients are advised to take the medicines daily with food and avoid milk, antacids, or other cation-rich products that can reduce effectiveness,” the guidelines state.
One of the key benefits of the new guidelines is preventing patients from discontinuing treatment, says Dr Sameer Bansal, Senior Consultant Pulmonologist at Vaayu Chest and Sleep Specialists and Apollo Hospital, Bengaluru.
He noted the long duration of previous TB treatments often caused patients to discontinue therapy before completing the full course.
“This led to low cure rates, about 55 to 60 percent for drug-resistant TB. Shortening the regimen with fewer and more effective drugs majorly aims to target this problem,” he said.
Dr Bansal also highlighted why these shorter regimens are particularly relevant for India since prolonged treatment schedules, combined with multiple drugs, had previously led to higher costs for TB programmes and significant challenges in patient follow-up.
“India has already adopted this and the results are already good. Follow-up over longer treatment durations was a major problem, along with multiple drugs in the regimen leading to higher cost to the programme. In addition to this, cumulative side effects of medications over longer periods led to frequent erratic treatment behaviour, leading to lower cure rates,” he explained.
Dr Bansal said the updated guidelines are expected to benefit patients, healthcare providers, and the country as a whole.
For patients, shorter courses with fewer side effects improve the likelihood of completing therapy. For government TB programmes, reduced follow-up burdens, better cure rates, and fewer challenges with drug supply are anticipated.
“It is likely to have a positive impact for sure due to all the points mentioned above,” he said.
Apart from the time and cost benefits for patients, Dr Suresh, Senior Consultant Pulmonologist at SIMS Hospital, Chennai, said that research supports faster healing and better action against dormant bacilli, bacteria that can remain in the body and cause recurrence when immunity drops.
“Shorter regimens are always better. When a patient’s immunity drops, these dormant bacteria can become active again and cause TB to return,” he said, adding that the new regimens aim to target these hidden bacteria and reduce the chances of recurrence.
Dr Suresh pointed out a major shift in the drug lineup: Ethambutol is out, Moxifloxacin is in. The newer drug not only attacks TB more effectively but also targets the dormant bacteria that often fuel relapse.
Ethambutol, he explained, was useful in reducing a patient’s infectiousness in the first weeks, but Moxifloxacin offers a stronger effect overall. He added that Rifampin has been replaced by Rifapentine, a longer-acting alternative, though he warned it is costly and not yet widely available in India.
The new regimens could potentially be a “game changer”, Dr Suresh said, but their actual impact in a high-burden country like India remains uncertain.
“This has been implemented in a place where the incidence of tuberculosis is low, like in the US. For a higher incidence country, whether this will be a game changer, we have to wait and see,” he said.
He explained that while private hospitals do see TB patients, more complex cases and larger numbers are treated in government hospitals.
“Eighty percent of our country’s healthcare is given by the private setup. But tuberculosis is seen more commonly in the government setup, so they do a lot more of tuberculosis compared to us,” he said.
Looking ahead, Dr Suresh stressed the need for research within the Indian healthcare system before adopting the regimens widely.
“We need more research in our setup in order to implement this change,” he said. He also underlined the importance of cost analysis, since the government provides TB drugs free of cost in public hospitals.
“The government has to work out how much cost this will put on healthcare,” he added.
(Edited by Dese Gowda)
