Bedaquiline !

A key all-oral drug for drug-resistant tuberculosis that cuts off the bacillus's energy supply. Its main risk is QT prolongation, so ECGs are done.

Updated 2026-11-01

Class: Antituberculosis drugs
Enzyme: ATP synthase, subunit c (M. tuberculosis)
ATC code: J04AK05
WHO Model List of Essential Medicines

Also called: BDQ, Bdq

ATP synthase, subunit c (M. tuberculosis)Bedaquiline

The figure shows bedaquiline bound to the Fo rotor of M. tuberculosis ATP synthase (cryo-EM).

Target in 3D: ATP synthase, subunit c (M. tuberculosis). PDB structure 8J57 (RCSB PDB, public domain). View the structure at RCSB PDB

Mechanism of action

Bedaquiline binds subunit c of the mycobacterial ATP synthase and jams its rotor, so protons can no longer drive ATP production. Without energy, both growing and dormant bacilli die. Resistance comes from atpE mutations or from efflux pump changes, which can also cause cross-resistance with clofazimine.

Bedaquiline binds the c subunit of ATP synthase
The rotor stops turning
ATP runs out and the bacillus dies

Pharmacokinetics

Absorption: By mouth, with a delay; food increases absorption
Distribution: Huge volume of distribution; it builds up in tissues and inside cells
Metabolism: CYP3A4, to the M2 metabolite that drives QT prolongation
Half-life: Very long terminal phase (months), from slow release out of tissues

Indications

Multidrug- or rifampicin-resistant tuberculosis (BPaLM, BDLLfxC and 9-month or longer regimens) Tuberculosis →
Drug-resistant pulmonary tuberculosis Pulmonary tuberculosis →

Adverse effects

Common

Nausea, diarrhoea
Joint and muscle pain
Headache
Rash, itching, dry skin

Contraindications

Hypersensitivity to bedaquiline
Great caution with a long QT, slow or irregular heartbeat, heart failure, recent heart attack, untreated hypothyroidism or low potassium, calcium or magnesium

Key interactions

Strong CYP3A4 inducers (rifampicin, rifapentine) and rifabutin: Lower bedaquiline levels: avoided
Efavirenz: Lowers bedaquiline: not co-administered; dolutegravir-based ART is preferred
CYP3A4 inhibitors, including boosted HIV protease inhibitors: Raise bedaquiline: closer ECG monitoring
Other QT-prolonging drugs (clofazimine, delamanid, fluoroquinolones): QT effects add up: serial ECGs

What is monitored

ECG before starting and repeatedly during treatment
Potassium, calcium and magnesium
Liver tests and symptoms of hepatitis
Sputum smear and culture response

Administration and safety

By mouth with food
Tablets can be dispersed or crushed into soft food when swallowing is hard
Always combined with other effective TB drugs, never alone
Alcohol is avoided during treatment

Nursing care

Check the ECG schedule and electrolytes are kept
Teach to report palpitations, dizziness or fainting at once
Teach the signs of liver injury
Review every medicine for QT effects and CYP3A4 interactions
Support adherence through the whole regimen

Pregnancy and breastfeeding

A pregnancy is reported to the treating team; because bedaquiline stays in the body for a very long time, breastfeeding is avoided during treatment and for a long period after the last dose.

Test yourself

Think of the answer, then tap the question to see it.

What is bedaquiline's target?

Subunit c of the mycobacterial ATP synthase: it blocks the bacillus's energy production.

Which test is repeated during bedaquiline treatment, and why?

The ECG, because bedaquiline (through its M2 metabolite) prolongs the QT interval.

Why is bedaquiline not given with rifampicin?

Rifampicin strongly induces CYP3A4 and lowers bedaquiline levels.

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Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.

Sources: Bedaquiline: MedlinePlus Drug Information (MedlinePlus (U.S. National Library of Medicine), 2025); WHO consolidated guidelines on tuberculosis: module 4: treatment and care (World Health Organization (WHO), 2025); ATCDDD - ATC/DDD Index (WHO Collaborating Centre for Drug Statistics Methodology, 2026); Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed., ch. 65 (McGraw Hill, 2023).

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Representative model, for educational purposes only.