This study aims to assess quabodepistat-based treatment regimens for RR/MDR-TB. The study will enroll adults and adolescents with rifampicin-resistant or multidrug-resistant pulmonary TB. The main goal is to see if a new drug called quabodepistat, when combined with other TB drugs, can shorten treatment duration to 4 months and be as effective and safer than current WHO endorsed treatment regimen given for 6-months. The study will compare different drug combinations in two groups of patients: those whose TB is sensitive to fluoroquinolones and those whose TB is resistant to fluoroquinolones. Participants will be randomly assigned to receive either the new treatment or the standard treatment. The study will last for 16 months for each participant and will measure how well the treatments work and how safe they are.

This is a Phase 3, randomized, open-label, multicenter trial evaluating quabodepistat-containing regimens for rifampicin-resistant/multidrug-resistant (RR/MDR) pulmonary tuberculosis (TB).

The study aims to enroll 532 participants aged 14 years and older.

The study has two main cohorts:

Fluoroquinolone-sensitive RR/MDR-TB (432 participants):

• Experimental arm: BPaQM (bedaquiline, pretomanid, quabodepistat, moxifloxacin) for 4 months
• Control arm: BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin) for 6 months

Fluoroquinolone-resistant RR/MDR-TB (100 participants):

• Experimental arm: BPaQ (bedaquiline, pretomanid, quabodepistat) for 6 months
• Control arm: BPaL (bedaquiline, pretomanid, linezolid) for 6 months

The primary efficacy endpoint is an unfavorable outcome by 12 months post-randomization.

Secondary endpoints include time to unfavorable outcome, time to sputum culture conversion, and safety/tolerability assessments. Participants will be followed for 16 months post-randomization.

The study will be conducted at approximately 40 sites in up to 12 countries.

An independent Data Monitoring Committee and Endpoint Adjudication Committee will be used in the study.

The trial aims to evaluate if quabodepistat-containing regimens can shorten treatment duration to 4 months for fluoroquinolone-sensitive RR/MDR-TB and provide a safer alternative to linezolid-containing regimens for both fluoroquinolone-sensitive and fluoroquinolone-resistant RR/MDR-TB.

Inclusion Criteria:

1. Age ≥14 years
2. Body weight ≥30.0 kg
3. Able to provide written informed consent (if under 18, requires both participant assent and parent/guardian consent)
4. Documented pulmonary TB: Mtb confirmed by Xpert MTB/RIF Ultra (semi-quantitative result of 'low', 'medium', or 'high')
5. Rifampicin resistance confirmed by Xpert MTB/RIF Ultra test
6. Chest radiograph consistent with active TB disease
7. Able to provide sputum sample
8. Participants of childbearing potential must use 2 different approved birth control methods during treatment and for 12 weeks after last dose
9. Willing to have HIV test (unless previous positive result confirmed)
10. For HIV-positive participants: On stable antiretroviral regimen (dolutegravir, lamivudine/emtricitabine, tenofovir) for ≥3 months, Viral load <200 copies/mL, and CD4 count >100 cells/mL

Exclusion Criteria:

1. Known/suspected resistance to BDQ, PMD, LZD, or QBS
2. Prior treatment with BDQ, PMD, LZD, DLM, QBS, or DprE1 inhibitors for ≥1 month within past 3 months
3. Severe extrapulmonary TB
4. Abnormal laboratory values: ALT/AST >2.5×ULN, Total bilirubin >1.5×ULN, eGFR <60 mL/min/1.73m², Hemoglobin <8 g/dL, Platelets <100,000 cells/mm³, WBC <2.0×10⁹/L, ANC <1000 cells/μL, and HbA1c >9.0%
5. Pre-existing peripheral neuropathy (≥Grade 1), optic neuritis, or visual impairment
6. Co-enrollment in other therapeutic trials
7. QTcF >450 msec (males) or >470 msec (females)
8. Clinically significant cardiovascular disorders
9. Bleeding disorders
10. Conditions interfering with X-ray or sputum assessment
11. Drug allergies/hypersensitivity to study medications
12. Pregnancy or breastfeeding
13. Positive drug screen (case-by-case assessment for some substances)
14. Serious mental disorders
15. Karnofsky score <60
16. BMI <16.0 kg/m²
17. Significant comorbidities (metabolic, renal, gastrointestinal, neurological, psychiatric, endocrine, liver)
18. Pulmonary conditions other than TB (silicosis, fibrosis)
19. Active SARS-CoV-2 infection
20. Use of prohibited medications
21. Blood/plasma donation within 30 days
22. Current use of herbal remedies or traditional medicines

Anonymized individual participant data (IPD) that underlie the results of this study will be shared with researchers to achieve aims pre-specified in a methodologically sound research proposal. Small studies with less than 25 participants are excluded from data sharing.

Data will be available after marketing approval in global markets, or beginning 1-3 years following article publication. There is no end date to the availability of the data.

Otsuka will share data on the Vivli data sharing platform: https://vivli.org/ourmember/Otsuka/

This is an open-label study with blinded endpoint adjudication of the primary efficacy outcome. Certain sponsor team members will be blinded to treatment assignments to minimize potential bias as much as possible