Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart
  • Log out

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions

Faster for less: the new “shorter” regimen for multidrug-resistant tuberculosis

Giovanni Sotgiu, Simon Tiberi, Lia D'Ambrosio, Rosella Centis, Jan Willem Alffenaar, Jose A. Caminero, Marcos Abdo Arbex, Valentina Alarcon Guizado, Alena Aleksa, Simone Dore, Mina Gaga, Gina Gualano, Heinke Kunst, Marie-Christine Payen, Aurora Jazmín Roby Arias, Alena Skrahina, Ivan Solovic, Giorgia Sulis, Marina Tadolini, Alimuddin Zumla, Giovanni Battista Migliori for the International Carbapenem Study Group
European Respiratory Journal 2016 48: 1503-1507; DOI: 10.1183/13993003.01249-2016
Giovanni Sotgiu
1Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: giovannibattista.migliori@fsm.it
Simon Tiberi
2Division of Infection, Barts Health NHS Trust, London, UK
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Lia D'Ambrosio
3Fondazione S. Maugeri, IRCCS, Care and Research Institute, Tradate, Italy
4Public Health Consulting Group, Lugano, Switzerland
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Rosella Centis
3Fondazione S. Maugeri, IRCCS, Care and Research Institute, Tradate, Italy
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jan Willem Alffenaar
5Dept of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jose A. Caminero
6Pneumology Dept, Hospital General de Gran Canaria “Dr. Negrin”, Las Palmas de Gran Canaria, Spain
7MDR-TB Unit, Tuberculosis Division, International Union against Tuberculosis and Lung Disease (The Union), Paris, France
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Marcos Abdo Arbex
8University Center of Araraquara, Sao Paulo, Brazil
9Hospital Nestor Goulart Reis, Sao Paulo State Secretary of Health, Sao Paulo, Brazil
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Valentina Alarcon Guizado
10National Tuberculosis Control Programme, Ministry of Health, Lima, Peru
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alena Aleksa
11Educational Institution “Grodno State Medical University”, Grodno, Belarus
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Simone Dore
1Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mina Gaga
12MDR-TB Unit, Athens Chest Hospital Sotira, National Referral Centre for Mycobacteria, Athens, Greece
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gina Gualano
13Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases ‘L. Spallanzani’ IRCCS, Rome, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Heinke Kunst
14Dept of Respiratory Medicine, Queen Mary University, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Marie-Christine Payen
15Division of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Aurora Jazmín Roby Arias
16National Tuberculosis Control Programme, Pulmonology Hospital Alfredo J. Valenzuela, Guayaquil, Ecuador
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alena Skrahina
17Republican Research and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ivan Solovic
18National Institute for TB, Lung Diseases and Thoracic Surgery, Vysne Hagy, Catholic University Ruzomberok, Ružomberok, Slovakia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Giorgia Sulis
19University Dept of Infectious and Tropical Diseases, WHO Collaborating Centre for TB/HIV Co-infection and for TB Elimination - University of Brescia and Brescia Spedali Civili General Hospital, Brescia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Giorgia Sulis
Marina Tadolini
20Unit of Infectious Diseases, Dept of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alimuddin Zumla
21Division of Infection and Immunity, University College London and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
22These authors contributed equally
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Giovanni Battista Migliori
3Fondazione S. Maugeri, IRCCS, Care and Research Institute, Tradate, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Giovanni Battista Migliori
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Evaluation of drug resistances is needed to identify candidates for the shorter regimen in MDR-TB hot spots http://ow.ly/wZV33022VXt

To the Editor:

Multidrug resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) are growing clinical and public health concerns, with an estimated worldwide incidence and mortality of 480 000 and 190 000 cases, respectively (2014) [1]. The World Health Organization (WHO) End TB Strategy reiterates the MDR-/XDR-TB threat and the solutions to control the epidemic [2]. Unfortunately, large proportions of patients with resistant TB do not have access to adequate diagnostics and treatment yet, while treatment success rates remain suboptimal (as demonstrated in the largest retrospective cohort of MDR-TB patients, i.e., TB caused by Mycobacterium tuberculosis isolates resistant to at least isoniazid and rifampicin) and decrease further with resistance patterns beyond XDR-TB [3].

Presently, several of the available drugs have limited efficacy, being either toxic or unobtainable or both, and the treatment may take up to 24 months or longer. Although a few, new and repurposed drugs are fortunately available, clinicians often have difficulties in designing effective regimens [4], due to lack of drugs and rapid diagnostics, susceptibility results, comorbidities, drug toxicities and tolerability.

Recently, WHO published new recommendations aimed at speeding up TB second-line drug resistance detection (rapid molecular MTBDRsl test) and improving treatment outcomes of MDR-TB cases (shorter MDR-TB regimen) [5]. This is a demonstration of the efforts urgently being made to provide wider access to diagnosis and treatment in countries with the highest burden of MDR-TB. WHO has highlighted the advantages of the new regimen (consisting of 4–6 months of kanamycin, moxifloxacin, prothionamide, clofazimine, pyrazinamide, high-dose isoniazid and ethambutol followed by 5 months of moxifloxacin, clofazimine, pyrazinamide and ethambutol), providing a fact sheet with the necessary explanations. They include its shorter duration (9–11 months), which will improve adherence and its “relatively” low cost (<1000 US dollars per patient), which will ensure sustainability; these features are extremely important in resource-limited settings and in rich countries. It is possible that the antibiotic regimen may be modified: for example kanamycin is likely to be replaced by capreomycin or amikacin and these modifications may increase the overall cost of the regimen [6].

The regimen is recommended for MDR-TB cases not resistant to, and never treated with second-line anti-TB drugs and, therefore, should not be used if there is a documented or suspected resistance or previous use of one of the drugs composing the regimen [5]. The new push towards broader molecular testing at an earlier stage will enable patients to be selected for the shorter MDR-TB regimen more readily and safely by reducing the window of resistance, laboratory errors and turn-around times. If resistances are present for one or more drugs in the shorter regimen then it could be argued that, possibly, these could be replaced with linezolid, delamanid or bedaquiline and still maintain a shorter treatment duration; however, there is not sufficient evidence presently available to recommend this [5].

Resistance to pyrazinamide, even if determined by reliable drug-susceptibility testing (DST) is not an absolute contraindication for the shorter MDR-TB regimen, unless there are accompanying elements indicating that one or more other agents in the regimen are also ineffective. It is not recommended to base treatment decisions on the DST for ethambutol owing to the unreliable nature of the test. There is no reliable DST available for clofazimine or prothionamide at this stage.

A question clinicians will ask is whether the shorter MDR-TB regimen is likely to work in all settings and especially outside trial conditions. However, the fundamentals of the shorter regimens are practically the same of the previous conventional 24-month regimens. They are using practically the same number of drugs, including a fluoroquinolone, a second-line injectable, and two other companion drugs. The only difference is that the fluoroquinolone should be moxifloxacin (used in many conventional 24-month MDR-TB regimens), and the replacement of cycloserine with clofazimine.

The International Carbapenems Study Group recently carried out a multi-centre, observational, retrospective, cohort study performed in centres specialised in the management of MDR-/XDR-TB cases in 11 countries, out of which eight (72.7%) were in Europe and three (27.3%) were in South America, including 348 patients in total [7–9]. Individuals aged <15 years were excluded. Only adults with a culture-confirmed diagnosis of MDR-TB were enrolled, and evaluated according to meropenem/imipenem-containing and -sparing regimens. The prevalence of resistances to the drugs included in the “shorter MDR-TB regimen” is summarised in table 1. We noted high proportional resistance to ethambutol and pyrazinamide (>60%,) prothionamide (55.4%;), fluoroquinolones (40.8%) and kanamycin (44.4%) (there were no data on clofazimine or high-dose isoniazid). In South America, we noticed higher prevalence of resistance to fluoroquinolones (86.8%) and kanamycin (67.9%), probably due to the selection of complicated cases in reference centres, with higher proportions of retreatment cases compared with the European patients.

View this table:
  • View inline
  • View popup
TABLE 1

Proportional prevalence of anti-tuberculosis drug-resistance in the International Carbapenems Study Group cohort

Our results suggest that a shorter MDR-TB regimen in our cohort would have an impact on only a minority of patients and may have limited use in these settings where patients have more resistant forms of TB and are more treatment experienced (like in reference centres); only 14 (4.0%) out of 348 new and retreated patients were susceptible to all the shorter MDR-TB regimen drugs (high-dose isoniazid and clofazimine resistance is unknown as both not routinely tested).

The lack of susceptibility to the new regimen was replicated even in the new patients' subgroup in our cohort (145 patients). Our study has a number of limitations given that it is retrospective, our cohort is super selected with a large representation of resistant cases with few therapeutic options, and is by definition not representative of the European and Latin America settings.

The study supporting the WHO recommendation is solid, being based on a multi-centre study including 1200 patients. The WHO analysis provides a strong evidence-based backbone to the implementation of this innovative regimen. It will favour an improvement of patient adherence and of drug safety and tolerability profile. However, a cautious decision-making approach, based on DST, is necessary, particularly in “hot spots” for MDR-/XDR-TB (e.g., former Soviet Union Countries) in new and previously treated cases. The “shorter MDR-TB regimen” will be a useful tool in the fight against MDR-/XDR-TB if properly utilised.

Critics are concerned that the programmatic management of MDR-TB with a shorter MDR-TB regimen may in turn lead to the selection of XDR-TB cases; however, at present, there is no evidence to substantiate for this, as shorter regimens have produced excellent outcomes under operational research conditions in some settings [10–12]. The opposite may be true, as the availability of a shorter MDR-TB regimen will allow for more patients to be treated and increase the chances of completing treatment, and this ultimately will reduce numbers of MDR-TB patients and the prevalence of XDR-TB patients over time. Currently the strongest risk factor for a bacteriologically unfavourable outcome with the shorter MDR-TB regimen consists of high-level fluoroquinolone resistance, particularly when compounded by initial pyrazinamide resistance [12]. If local epidemiology is known and rapid MTBDRsl testing used to ensure susceptibility for the key drugs composing the regimen, the shorter MDR-TB regimen could be very important for some patients as treatment duration is significantly reduced. To further safeguard the regimen, drug exposure may be evaluated. This will reduce the chance of development of drug resistance. Nowadays, simple tools are available which limit the use of therapeutic drug monitoring not only to the reference centre [13]. Apart from the selection of treatment based on DST it will then be up to the clinician to tailor the regimen based on the extensiveness of the disease, its location, monitoring of toxicities and psychological wellbeing and compliance of the patient, taking into account what WHO recommends to keep the MDR-TB regimen “shorter” [5, 14]. The importance of cohort discussion and “consilia” for the evaluation of MDR-TB patients could be a useful decisional tool in determining the appropriateness of the shorter MDR-TB regimen and in ensuring its maximum effectiveness [15].

Acknowledgements

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions and policies of their institutions.

All authors contributed to the conception of the study, data analysis, interpretation of the results, drafting of the manuscript and approval of the final version.

Members of the International Carbapenem Study Group: M. Abdo Arbex (Brazil), O.W. Akkerman (The Netherlands), E. Alarcon Arrascue (Peru), V. Alarcon Guizado (Peru), A. Aleksa (Belarus), J.W. Alffenaar (The Netherlands), J. Artsukevich (Belarus), V. Avchynka (Belarus), J.A. Caminero (Spain), R. Centis (Italy), L. D'Ambrosio (Italy), S. De Lorenzo (Italy), S. Dore (Italy), M. Gaga (Greece), G. Gualano (Italy), A.J. Roby Arias (Ecuador), E.H. Bonini (Brazil), F.A. Chong Marín (Ecuador), G. de Vries (The Netherlands), S. Dore (Italy), H. Kunst (UK), A. Matteelli (Italy), G.B. Migliori (Italy), C. Moschos (Greece), F. Palmieri (Italy), A. Papavasileiou (Greece), M.C. Payen (Belgium), A. Piana (Italy), A. Scardigli (France), A. Skrahina (Belarus), I. Solovic (Slovakia), G. Sotgiu (Italy), A. Spanevello (Italy), G. Sulis (Italy), M. Tadolini (Italy), S. Tiberi (UK), D. Vargas Vasquez (Peru), P. Viggiani (Italy), V. White (UK), A. Zumla (UK).

Footnotes

  • Conflict of interest: None declared.

  • Received June 23, 2016.
  • Accepted June 24, 2016.
  • Copyright ©ERS 2016

References

  1. ↵
    World Health Organization. Global Tuberculosis Report 2015. WHO/HTM/TB/2015.22. Geneva, World Health Organization, 2015.
  2. ↵
    1. Falzon D,
    2. Mirzayev F,
    3. Wares F, et al.
    Multidrug-resistant tuberculosis around the world: what progress has been made? Eur Respir J 2015; 45: 150–160.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Migliori GB,
    2. Sotgiu G,
    3. Gandhi NR, et al.
    Drug resistance beyond extensively drug resistant tuberculosis: individual patient data meta-analysis. Eur Respir J 2013; 42: 169–179.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Caminero JA,
    2. Scardigli A
    . Classification of antituberculosis drugs: a new proposal based on the most recent evidence. Eur Respir J 2015; 46: 887–893.
    OpenUrlAbstract/FREE Full Text
  5. ↵
    WHO treatment guidelines for drug-resistant tuberculosis. 2016 update WHO/HTM/TB/2016.04. Geneva, World Health Organization, 2016.
  6. ↵
    1. Diel R,
    2. Vandeputte J,
    3. de Vries G, et al.
    Costs of tuberculosis disease in the European Union: a systematic analysis and cost calculation. Eur Respir J 2014; 43: 554–565.
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Tiberi S,
    2. Payen MC,
    3. Sotgiu G, et al.
    Effectiveness and safety of meropenem/clavulanate-containing regimens in the treatment of multidrug and extensively drug-resistant tuberculosis. Eur Respir J 2016; 47: 1235–1243.
    OpenUrlAbstract/FREE Full Text
    1. Tiberi S,
    2. Sotgiu G,
    3. D'Ambrosio L, et al.
    Comparison of effectiveness and safety of imipenem/clavulanate-versus meropenem/clavulanate-containing regimens in the treatment of multidrug and extensively drug-resistant tuberculosis. Eur Respir J 2016; 47: 1758–1766.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Tiberi S,
    2. Sotgiu G,
    3. D'Ambrosio L, et al.
    Effectiveness and safety of imipenem-clavulanate added to an optimized background regimen (OBR) versus OBR control regimens in the treatment of multidrug-resistant and extensively drug-resistant tuberculosis. Clin Infect Dis 2016; 62: 1188–1190.
    OpenUrlFREE Full Text
  9. ↵
    1. Piubello A,
    2. Harouna SH,
    3. Souleymane MB, et al.
    High cure rate with standardised short-course multidrug-resistant tuberculosis treatment in Niger: no relapses. Int J Tuberc Lung Dis 2014; 18: 1188–1194.
    OpenUrlCrossRefPubMed
    1. Van Deun A,
    2. Maug AK,
    3. Salim MA, et al.
    Short, highly effective, and inexpensive standardized treatment of multidrug-resistant tuberculosis. Am J Respir Crit Care Med 2010; 182: 684–692.
    OpenUrlCrossRefPubMedWeb of Science
  10. ↵
    1. Aung KJ,
    2. Van Deun A,
    3. Declercq E, et al.
    Successful ‘9-month Bangladesh regimen’ for multidrug-resistant tuberculosis among over 500 consecutive patients. Int J Tuberc Lung Dis 2014; 18: 1180–1187.
    OpenUrlCrossRefPubMed
  11. ↵
    1. Ghimire S,
    2. Bolhuis MS,
    3. Sturkenboom MG, et al.
    Incorporating therapeutic drug monitoring into the World Health Organization hierarchy of tuberculosis diagnostics. Eur Respir J 2016; 47: 1867–1869.
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Tiberi S,
    2. D'Ambrosio L,
    3. De Lorenzo S, et al.
    Tuberculosis elimination, patients’ lives and rational use of new drugs: revisited. Eur Respir J 2016; 47: 664–667.
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. D'Ambrosio L,
    2. Tadolini M,
    3. Dupasquier S, et al.
    ERS/WHO tuberculosis consilium: reporting of the initial 10 cases. Eur Respir J 2014; 43: 286–289.
    OpenUrlFREE Full Text
View Abstract
PreviousNext
Back to top
View this article with LENS
Vol 48 Issue 5 Table of Contents
European Respiratory Journal: 48 (5)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Faster for less: the new “shorter” regimen for multidrug-resistant tuberculosis
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Faster for less: the new “shorter” regimen for multidrug-resistant tuberculosis
Giovanni Sotgiu, Simon Tiberi, Lia D'Ambrosio, Rosella Centis, Jan Willem Alffenaar, Jose A. Caminero, Marcos Abdo Arbex, Valentina Alarcon Guizado, Alena Aleksa, Simone Dore, Mina Gaga, Gina Gualano, Heinke Kunst, Marie-Christine Payen, Aurora Jazmín Roby Arias, Alena Skrahina, Ivan Solovic, Giorgia Sulis, Marina Tadolini, Alimuddin Zumla, Giovanni Battista Migliori
European Respiratory Journal Nov 2016, 48 (5) 1503-1507; DOI: 10.1183/13993003.01249-2016

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Faster for less: the new “shorter” regimen for multidrug-resistant tuberculosis
Giovanni Sotgiu, Simon Tiberi, Lia D'Ambrosio, Rosella Centis, Jan Willem Alffenaar, Jose A. Caminero, Marcos Abdo Arbex, Valentina Alarcon Guizado, Alena Aleksa, Simone Dore, Mina Gaga, Gina Gualano, Heinke Kunst, Marie-Christine Payen, Aurora Jazmín Roby Arias, Alena Skrahina, Ivan Solovic, Giorgia Sulis, Marina Tadolini, Alimuddin Zumla, Giovanni Battista Migliori
European Respiratory Journal Nov 2016, 48 (5) 1503-1507; DOI: 10.1183/13993003.01249-2016
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Acknowledgements
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • Respiratory infections and tuberculosis
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Agora

  • Airway immune responses to COVID-19 vaccination in COPD patients
  • Wider access to rifapentine-based regimens is needed for TB care globally
  • Screening for PVOD in heterozygous EIF2AK4 variant carriers
Show more Agora

Research letters

  • Airway immune responses to COVID-19 vaccination in COPD patients
  • Wider access to rifapentine-based regimens is needed for TB care globally
  • Screening for PVOD in heterozygous EIF2AK4 variant carriers
Show more Research letters

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society