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# 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](https://durgical.com/en/pharmacology/classes/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](https://www.rcsb.org/structure/8J57) · Drag to rotate · pinch to zoom

## 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 →](https://durgical.com/en/conditions/tuberculosis/)
- Drug-resistant pulmonary tuberculosis [Pulmonary tuberculosis →](https://durgical.com/en/conditions/pulmonary-tuberculosis/)

## Adverse effects

### Common

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

### Serious (rare, important)

- QT prolongation and dangerous arrhythmias
- Liver injury (jaundice, dark urine, pain in the right upper abdomen)

## 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.

## Memory aid

BedaQuiline: Battery cut (ATP synthase) and QT up.

## 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.

[Add to my cards (3)](https://durgical.app/estudiar/?add=/en/pharmacology/bedaquiline/)

## Related drugs

- [Pretomanid](https://durgical.com/en/pharmacology/pretomanid/)
- [Delamanid](https://durgical.com/en/pharmacology/delamanid/)
- [Clofazimine](https://durgical.com/en/pharmacology/clofazimine/)
- [Moxifloxacin](https://durgical.com/en/pharmacology/moxifloxacin/)

## Related conditions

- [Tuberculosis](https://durgical.com/en/conditions/tuberculosis/)
- [Pulmonary tuberculosis](https://durgical.com/en/conditions/pulmonary-tuberculosis/)

[← Back to the class: Antituberculosis drugs](https://durgical.com/en/pharmacology/classes/antituberculosis-drugs/)

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](https://medlineplus.gov/druginfo/meds/a613022.html) (MedlinePlus (U.S. National Library of Medicine), 2025); [WHO consolidated guidelines on tuberculosis: module 4: treatment and care](https://www.who.int/publications/i/item/9789240107243) (World Health Organization (WHO), 2025); [ATCDDD - ATC/DDD Index](https://atcddd.fhi.no/atc_ddd_index/?code=J04AK05) (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.

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