HIV+ pregnancy: isoniazid best given postpartum to optimise outcomes

  • Gupta A & al.
  • N Engl J Med
  • 3 Oct 2019

  • International Clinical Digest
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Takeaway

  • Initiation of isoniazid during vs after pregnancy is noninferior with regard to maternal adverse events (AEs) in HIV-infected pregnant women on antiretroviral therapy (ART) but is linked to a higher composite adverse outcome.
  • The composite outcome included stillbirth or spontaneous abortion, low infant birth weight, preterm delivery, or congenital anomalies.

Why this matters

  • Consider administering isoniazid to ART-treated, HIV-infected pregnant women during postpartum vs immediate pregnancy period.
  • Shorter courses (i.e., 1 or 3 months) might optimise outcomes.

Key results

  • 956 participants (477 immediate, 479 deferred isoniazid).
  • Composite adverse pregnancy outcomes: 23.6% for immediate vs 17.0% for deferred use (difference, 6.7 percentage points; P=.01).
  • Intent-to-treat (ITT) population: grade ≥3 maternal AEs were similar with immediate and deferred use (15.1% vs 15.2%; incidence rate, 15.03 vs 14.93 per 100 person-years [PY]; Δ=0.10; 95% CI, −4.77 to 4.98).
  • ITT: incidence rate for any grade 3/4 AE was likewise similar (34.95 vs 31.26 per 100 PY; Δ=3.69 [95% CI, −4.07 to 11.45]).
  • Hepatotoxicity incidence rates were similar (5.80 vs 6.69 per 100 PY; Δ=−0.89 [95% CI, −3.98 to 2.19]).
  • 6 postpartum deaths (2 immediate, 4 deferred); rate difference, −0.39 (95% CI, −1.33 to 0.56).

Study design

  • Multicentre, double-blind, noninferiority trial assessing immediate vs deferred initiation of isoniazid through week 48 postdelivery among HIV-infected pregnant women living in high-risk areas.
  • Funding: NIH.

Limitations

  • Noninferiority margin not reached.
  • Intensive laboratory monitoring, misclassifications.