New Delhi: The BPaLM regimen (Bedaquiline, Pretomanid, Linezolid, and Moxifloxacin) is being hailed as a breakthrough in the fight against multidrug-resistant tuberculosis (MDR-TB). But is it the ultimate answer to a disease that has plagued humanity for centuries?. Without proper execution, even the most advanced treatments remain ineffective. While BPaLM offers hope with a shorter, all-oral regimen, its impact is hindered by real-world barriers such as limited access, high costs, and sluggish implementation.
Experts highlight that BPaLM regimen drastically reduces duration of TB duration from 18–24 months to just six months, easing the burden on patients while demonstrating higher efficacy and fewer side effects. Yet, its promise is overshadowed by accessibility issues. Pricing and regulatory hurdles make the regimen out of reach for many in low-resource settings. Moreover, while it is a game-changer for MDR-TB, it is not a universal cure, and misuse could accelerate drug resistance, worsening an already dire crisis.
According to the WHO Global Tuberculosis Report 2024, India remains the world’s highest TB-burden country. While the nation has achieved a 17.7 per cent reduction in TB incidence from 2015 to 2023, surpassing the global decline of 8.3 per cent, the battle is far from over. In the first nine months of 2024 alone, India reported 1.988 million TB cases—a 4.2 per cent rise from the previous year, largely due to improved detection and reporting. Despite progress, India continues to account for a significant share of the global TB crisis, alongside Indonesia, China, the Philippines, and Pakistan.Terming the BPaLM regimen “patient-friendly,” Dr. Lancelot Pinto, Consultant Pulmonologist and Epidemiologist, P. D. Hinduja Hospital & Medical Research Centre in Mumbai, said, “The BPaLM regimen is short (six months), all-oral, and has a high success rate with fewer adverse effects. It will definitely bring about a change in treatment outcomes. The BPaLM regimen is specifically designed for those with MDR-TB. From a disease perspective, patients with MDR-TB have the poorest outcomes, and this regimen is likely to be a game-changer. However, from an epidemiological perspective, only 2.45 per cent of newly diagnosed TB patients in India have MDR-TB, while 12.8 per cent of those previously treated for TB develop drug resistance. Hence, improving MDR-TB treatment outcomes alone is unlikely to be the key driver in eradicating TB in India.”Dr Mrinal Sircar, Director of Pulmonology, Fortis Hospital, emphasised that BPaLM enhances patient adherence and reduces side effects. He stated, “The regimen aligns with India’s goal of ending TB by 2025—five years ahead of the global target—as it offers all the essential elements of an improved regimen: a high cure rate (>90 per cent), better patient adherence, a lower pill burden, shorter treatment duration, fewer side effects, and cost-effectiveness.”
While health experts remain optimistic, they stress that the success of the BPaLM regimen hinges on the right strategies and effective implementation. The regimen has been globally recognised as a powerful solution for MDR-TB, but its impact in India and other high-burden settings will depend on overcoming significant challenges.
Dr. V. R. Raman, Public Health Specialist and Advisor for TB Programs in India, pointed out the key obstacles: “Our supply chain needs significant strengthening, especially in states and areas with the highest TB prevalence. Continuous availability of all drugs must be ensured without any interruptions, as supply shortages have been a persistent challenge.”
Dr. Raman stressed the need for continuous observation and course correction for specific patient groups. “People with poor nutrition, lower BMI, diabetes, cardiac or neurological conditions require differentiated approaches. Equipping program leaders and grassroots medical practitioners with necessary skills to manage such cases has long been a weak link in TB control efforts. This gap demands urgent attention.”
On the rollout of BPaLM in India, Dr. Pinto remarked, “To the best of my knowledge, access to BPaLM is currently limited. How quickly it becomes universally available remains to be seen. The public sector has faced supply challenges with TB drugs in the past. Hopefully, lessons have been learned to ensure both access and supply for BPaLM.”
Dr. Pinto further emphasised that prevention remains a crucial pillar of TB elimination, which often does not receive enough attention. “TB is a socioeconomic disease, influenced by nutrition, poverty, and immunity. Steps like providing food rations and cash transfers to patients are positive developments. Additionally, promoting healthier lifestyles, addressing immunosuppressive conditions like diabetes, and implementing smoking cessation programs are essential. Treating latent TB infections must also be a priority if eradication is the goal.”
Early detection, Dr. Pinto noted, requires universal molecular testing, citing Goa’s success in achieving this. “Once detected, uninterrupted medication supply is key to ensuring a cure. Making TB a notifiable disease and regularly following up with patients to ensure adherence are positive steps. We must also address sub-clinical TB—cases that have not yet reached the healthcare system. Expanding the use of AI-based tools and radiology can help detect such cases earlier.”
Dr. Sircar acknowledged that India has made significant strides in expanding its TB laboratory network and integrating BPaLM into the National TB Elimination Program but warned that logistical and infrastructure challenges persist in rural and remote areas. “The government’s focus on capacity-building and improving healthcare infrastructure is a step in the right direction,” he said.
Dr. Sandeep Jain, Consultant Pulmonologist at Neotia Mediplus, expressed cautious optimism: “BPaLM is a relatively new regimen that has shown promising results. It has the potential to revolutionise DR-TB management, which has historically been difficult to treat. As more data emerges, we will be able to assess its true impact at the community level. Let’s hope this is the ‘magic combination’ we all need.”
Eradicating tuberculosis in India by 2025 may not be a reality, but a surgical strike with BPaLM as the most potent weapon in our arsenal offers hope. However, its effectiveness hinges on rapid deployment, universal drug-susceptibility testing, and an unbreakable supply chain. India must act with precision and urgency to turn this breakthrough into a decisive victory against TB.
