Accreditation/Credit Designation

Physicians' Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 1.5 Contact Hours.

Acknowledgment of Commercial Support

This activity is supported by an educational grant from Insmed Incorporated.

Provider & Caregiver Connection™: Patient Perspectives in Nontuberculous Mycobacterial Lung Disease

Release Date: July 31, 2019
Expiration Date: July 31, 2020
Media: Internet - based

Activity Overview

Nontuberculous mycobacteria (NTM) are mycobacteria that are not members of the species Mycobacterium tuberculosis or Mycobacterium leprae. Nontuberculous mycobacteria are ubiquitous in nature and most commonly isolated from soil and water, but also are found in biofilms coating the inside of showerheads. Exposure to environmental sources of NTM can lead to opportunistic infections, including severe pulmonary infections, and are especially common among those with genetic host defense defects and/or comorbidities, and negatively impact quality of life in those affected. Nontuberculous mycobacteria lung disease (NTM-LD) typically affects individuals age ˃60 years, and women are more likely than men to be affected. These mycobacteria are slow-growing pathogens, and many symptoms of NTM-LD, such as coughing, dyspnea, weight loss, and fatigue, mimic symptoms of such other respiratory ailments as bronchitis or chronic obstructive pulmonary disease, causing significant delays in diagnosis and appropriate treatment. Prevalence of NTM-LD is increasing in all regions of the United States and is especially prevalent along coastal regions.

This educational activity is highlighted with a patient’s perspective, from a 6-year journey to diagnosis, treatment challenges, lifestyle changes, and ongoing disease management. Two expert faculty will build on the patient’s narrative to share their experiences and practical insights on diagnosis with specific laboratory requirements, radiologic and clinical findings, and then current, new, and emerging treatments for this lifelong disease.

Benefits of Participating

  • Gain awareness and understanding of NTM-LD through a patient’s narrative from diagnosis to treatment
  • Understand the 3-pronged approach to diagnosis through laboratory, radiologic, and clinical findings
  • Recognize toxicities and monitoring requirements for standard treatment regimens
  • Learn about new and emerging treatments for refractory disease
  • Improve patient outcomes with strategies to individualize disease management

Acknowledgement of Commercial Support

This activity is supported by an educational grant from Insmed Incorporated.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review video files/content until you finish the presentation.
  • At the end of the activity, educational content/video files will be available for your reference.
  • In order to receive a CME/CE certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME/CE certificate upon completion of these steps.


Target Audience

This activity is intended for primary care physicians, infectious disease specialists, and pulmonologists. Physician assistants, nurse practitioners, and nurses involved in the diagnosis and management of NTM-LD will also be invited to participate.

Learning Objectives

Upon successful completion of this educational activity, you should be better prepared to:

  • Recognize the diagnostic approach to NTM-LD, including mycobacterial subspecies identification and evaluation of drug resistances
  • Evaluate the efficacy, toxicity, and drug interactions of antibiotics used in the treatment of NTM-LD
  • Incorporate patient perspectives into management of care and strategies to improve outcomes

Faculty, Staff, and Planners’ Disclosures

Faculty

Doreen J. Addrizzo-Harris
Doreen J. Addrizzo-Harris, MD
Professor of Medicine, NYU School of Medicine
Associate Division Director, Education and Faculty Affairs
Division of Pulmonary, Critical Care and Sleep Medicine
Program Director, Pulmonary and Critical Care Fellowship
Co-Director, NYULMC Pulmonary Associates
NYU Langone Health
New York, NY

Disclosures: Consultant: AIT Therapeutics.

Ashwin Basavaraj
Ashwin Basavaraj, MD, FCCP
Associate Director, Bronchiectasis Program
Assistant Program Director, Pulmonary Fellowship
NYU Langone Health
New York, NY

Disclosures: Consultant: Insmed Phamaceuticals (Consultant and Advisory Board), Hill-Rom.

Dariel Kirk (Patient Interviewee)

Disclosures: Dariel Kirk has no relevant financial relationships with commercial interests to disclose.

The staff of Physicians' Education Resource®, LLC (PER®), have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent clinical judgment of a physician or nurse relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members, and do not reflect those of PER® or any of the companies that provided commercial support for this program.

PER Pulse Recaps

1 of 3

PER Pulse™ Recap:
Provider and Caregiver Connection™:Patient Perspectives in Nontuberculous Mycobacteria Lung Disease

The online continuing medical education activity Provider and Caregiver Connection™:Patient Perspectives in Nontuberculous Mycobacteria Lung Disease features insights from a patient with nontuberculous mycobacteria (NTM) lung disease (NTM-LD) who described the journey through diagnosis, treatment, and lifestyle management in an engaging patient–provider discussion. Doreen J. Addrizzo-Harris, MD, and Ashwin Basavaraj, MD, built on this patient perspective, explaining first the clinical presentation of NTM-LD and then microbiologic testing and radiographic and clinical findings involved in an accurate diagnosis. Faculty next described the challenges of treating NTM-LD with specific regimens and the strategies for individualizing patient care to achieve best outcomes and quality of life.

This first of 3 PER Pulse™ Recaps will focus on increasing awareness of NTM-LD and its risk factors and categories, as explored in Provider and Caregiver Connection™: Patient Perspectives in Nontuberculous Mycobacteria Lung Disease.

NTM-LD is increasing worldwide, with about 100,000 new cases in 2018 in the United States alone. Prevalence is thought to be increasing, in part from improved laboratory culturing techniques and greater disease awareness. NTM are ubiquitous in the environment, with the heaviest concentrations found in soil and water. Due to biofilm formation, they can become resistant to disinfectants and antibiotics, and many of the Mycobacterium are resistant to high temperatures and relatively low pH.1 Bronchiectasis is frequently an underlying condition—over half of patients with bronchiectasis also have NTM-LD.

There are many risk factors for NTM-LD2:

  • Inflammatory conditions (lupus, rheumatoid arthritis)
  • Immunosuppression (chemotherapy or radiation treatment, HIV infection)
  • Reflux esophagitis
  • Primary conditions that result in bronchiectasis (chronic obstructive pulmonary disease, asthma, α1-antitrypsin deficiency, cystic fibrosis)
  • Geographic locations surrounded by water sources
  • Patient activities that increase exposure to NTM (gardening, swimming, hot tub use)

In addition, NTM-LD is increasingly identified in postmenopausal women with slender body habitus and individuals with scoliosis.

The >150 species of NTM are categorized as either slow or fast growing. The most common slow-growing species is Mycobacterium avium complex (MAC), which includes avium and intracellulare species and is found in about 80% of NTM-LD overall. The other 20% is generally from the fast-growing Mycobacterium abscessus and requires subspeciation based on the erm(41) gene to dictate treatment.

Key Points

  • NTM-LD is becoming increasingly prevalent worldwide.
  • Risk factors for NTM-LD include conditions that result in bronchiectasis, as well as immunosuppression, inflammatory conditions, and geographic location.
  • The majority of NTM-LD is due to the fast-growing MAC.

References

  1. Johnson MM, Odell JA. Nontuberculous mycobacterial pulmonary infections. J Thorac Dis. 2014;6(3):210-220. doi: 10.3978/j.issn.2072-1439.2013.12.24.
  2. Chan ED, Iseman MD. Underlying host risk factors for nontuberculous mycobacterial lung disease. Semin Respir Crit Care Med. 2013;34(1):110-123. doi: 10.1055/s-0033-1333573.

2 of 3

PER Pulse™ Recap:
Provider and Caregiver Connection™:Patient Perspectives in Nontuberculous Mycobacteria Lung Disease

As a follow-up to the online continuing medical education activity Provider and Caregiver Connection™:Patient Perspectives in Nontuberculous Mycobacteria Lung Disease, this second of 3 PER Pulse™ Recaps will focus on diagnosis of nontuberculous mycobacteria (NTM) lung disease (NTM-LD).

Diagnosis of NTM-LD is challenging because members of Mycobacterium occur naturally in the environment, and their isolation in pulmonary specimens is not necessarily indicative of clinical NTM-LD disease. In addition, NTM-LD can be misdiagnosed with other conditions such as reactive airways, asthma, recurrent pneumonias, and tuberculosis, and some slow-growing NTM can take a long time to culture—4 or more weeks. There is low awareness of NTM-LD in general, such that clinicians will not be considering it with the symptoms presented.

Clinical symptoms of NTM-LD include chronic cough and sputum production, weight loss, low-grade fever, malaise, and night sweats. According to Doreen Addrizzo-Harris, MD, associate director of Education and Faculty Affairs in the Division of Pulmonary, Critical Care, and Sleep Medicine at NYU Langone Health in New York, New York, “By the time most patients are getting diagnosed—and I’d say probably more than half—they are having significant sputum production and cough that has often been misdiagnosed as chronic obstructive lung disease or as recurrent episodes of bronchitis, when really, the underlying diagnosis is NTM-LD.”

Patients with recurring infections or chronic cough should have a computed tomography (CT) scan, because a chest x-ray can often miss bronchiectasis. Clinicians should look for the following in the CT scan:

  • Areas of bronchiectasis or dilated airways
  • Areas of bronchiolitis, a combination of nodules, and impacted mucus within the airways
  • Localization or diffuse bronchiectasis
  • Areas of cavity formation

With suspicion of NTM-LD in a CT scan, 3 sputum cultures (or a bronchoscopy in patients unable to produce sputum) should be sent to a laboratory equipped to perform speciation and antibiotic susceptibility.

Key Points

  • Diagnosis of NTM-LD is challenging because symptoms are similar to more common airway diseases, and clinicians may lack awareness for suspicion of it.
  • Diagnosis includes clinical findings and radiographic and microbiological data.
  • Multiple sputum samples should be sent to a laboratory with expertise in culturing Mycobacterium and performing and reporting susceptibility tests.

3 of 3

PER Pulse™ Recap:
Provider and Caregiver Connection™:Patient Perspectives in Nontuberculous Mycobacteria Lung Disease

As a follow-up to the online continuing medical education activity Provider and Caregiver Connection™:Patient Perspectives in Nontuberculous Mycobacteria Lung Disease, this third of 3 PER Pulse™ Recaps will focus on treatment of nontuberculous mycobacteria (NTM) lung disease (NTM-LD).

Treatment of NTM-LD is challenging and depends on the Mycobacterium isolated and drug susceptibility, severity of the NTM, and bronchiectasis and patient tolerance to lengthy, multidrug regimens. Not all patients will require immediate treatment, and the decision to start treatment can be difficult because disease progression is variable, without established disease predictors. Airway clearance should be considered first, along with treatment of underlying conditions such as acid reflux/aspiration or immunodeficiencies.

However, if the disease is progressing despite airway clearance and treatment of underlying conditions or if symptoms are worsening, then antibiotics should be initiated. Antibiotic therapy may take months to years, depending on the drug regimen and disease severity. The 2007 American Thoracic Society/Infectious Diseases Society of America guidelines provide specific multidrug regimens based on the severity of disease and species or subspecies of Mycobacterium.1 Antibiotics used in a typical 3-drug regimen include azithromycin or clarithromycin and rifampin or rifabutin and ethambutol. Mild disease may require therapy just 3 times weekly, but if cultures are not converting to negative or symptoms are progressing, therapy may be increased to daily or another antibiotic added. Adding amikacin liposome inhalation suspension (ALIS) to guideline-based therapy demonstrated significantly greater culture conversion after 6 months versus guideline-based therapy alone in patients with treatment-refractory NTM-LD caused by Mycobacterium avium complex (MAC).2 The most common adverse events experienced in clinical trials, dysphonia and cough, lessened over time as patients continued therapy.

Patients must be educated and monitored for potential drug toxicities of their multidrug regimen. These include gastrointestinal upset, rash, hearing loss, visual changes, and optic neuritis, as well as liver abnormalities. Treatment must be individualized to address allergies or intolerances to specific drugs, recognizing that drug resistance can occur, necessitating alternative therapies. Avoiding potential sources of Mycobacterium exposure (aerosolized water, soil, biofilms) is necessary to prevent reinfection.

Surgery is another treatment option for localized and more severe disease.

Once treated, patients should be followed lifelong to ensure that NTM-LD has not progressed and to initiate early treatment if disease recurs.

Key Points

  • Treatment of NTM-LD is lengthy, with a multidrug regimen based on Mycobacterium species or subspecies and disease severity.
  • Patients must be made aware of and educated on potential drug toxicities.
  • ALIS provides an additional option for patients with refractory MAC disease.

References

  1. Griffith DE, Aksamit T, Brown-Elliott BA, et al; ATS Mycobacterial Diseases Subcommittee; American Thoracic Society; Infectious Disease Society of America. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175(4):367-416.doi: 10.1164/rccm.200604-571ST.
  2. Griffith DE, Eagle G, Thomson R, et al; CONVERT Study Group. Amikacin liposome inhalation suspension for treatment-refractory lung disease caused by complex (CONVERT). a prospective, open-label, randomized study. Am J Respir Crit Care Med. 2018;198(12):1559-1569. doi: 10.1164/rccm.201807-1318OC.

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