[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Pharmacology](https://durgical.com/en/pharmacology/) › [Antituberculosis drugs](https://durgical.com/en/pharmacology/classes/antituberculosis-drugs/) › Pretomanid

[Pharmacology](https://durgical.com/en/pharmacology/) · [Antituberculosis drugs](https://durgical.com/en/pharmacology/classes/antituberculosis-drugs/)

# Pretomanid

A nitroimidazole prodrug for drug-resistant TB, the P in the 6-month BPaLM regimen. It kills both dividing and dormant bacilli; the liver is watched.

Updated 2026-11-01

- Class: [Antituberculosis drugs](https://durgical.com/en/pharmacology/classes/antituberculosis-drugs/)
- Enzyme: Deazaflavin-dependent nitroreductase Ddn (activating enzyme)
- ATC code: J04AK08
- WHO Model List of Essential Medicines

Also called: Pa, PA-824

## Mechanism of action

Pretomanid is a bicyclic nitroimidazole prodrug activated by the bacterial nitroreductase Ddn with the cofactor F420. In dividing bacilli it blocks mycolic acid production; in dormant, non-replicating bacilli it releases reactive nitrogen species such as nitric oxide that poison respiration and deplete ATP.

- Ddn and F420 activate pretomanid inside the bacillus
- Dividing bacilli: mycolic acid production is blocked
- Dormant bacilli: nitric oxide poisons respiration

## Pharmacokinetics

**Absorption**
Food increases exposure

**Metabolism**
Partly by CYP3A; inducers such as rifampicin lower its levels

## Indications

- Multidrug- or rifampicin-resistant tuberculosis and pre-XDR-TB, within BPaLM or BPaL [Tuberculosis →](https://durgical.com/en/conditions/tuberculosis/)
- Drug-resistant pulmonary tuberculosis [Pulmonary tuberculosis →](https://durgical.com/en/conditions/pulmonary-tuberculosis/)

## Adverse effects

### Common

- Rise in liver enzymes
- In BPaLM, linezolid adds myelosuppression and peripheral or optic neuropathy

### Serious (rare, important)

- Hepatotoxicity
- Effects on male fertility not yet fully studied

## Contraindications

- Use with strong or moderate CYP3A inducers (such as rifampicin)
- Hypersensitivity to pretomanid

## Key interactions

**Rifampicin and other CYP3A inducers**
Lower pretomanid levels: avoided

**Efavirenz**
Markedly lowers pretomanid: dolutegravir-based ART is preferred

## What is monitored

- Liver tests and symptoms of hepatitis
- Blood counts, vision and neuropathy symptoms (linezolid in the regimen)
- ECG (bedaquiline and moxifloxacin in the regimen)

## Administration and safety

- By mouth with food
- Only as part of the BPaLM or BPaL combination, never alone

## Nursing care

- Teach the signs of hepatitis
- Ask about tingling, numbness or vision changes (linezolid)
- Review antiretrovirals: efavirenz is not combined
- Support adherence: the regimen lasts only 6 months but every dose counts

## Memory aid

BPaLM: Bedaquiline, Pretomanid, Linezolid, Moxifloxacin: six months to beat MDR-TB.

## Test yourself

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

## Which regimen does pretomanid belong to?

BPaLM (or BPaL): bedaquiline, pretomanid, linezolid and moxifloxacin, for 6 months.

## How does pretomanid kill dormant bacilli?

After activation it releases nitric oxide and other reactive nitrogen species that poison respiration.

## Which antiretroviral is avoided with pretomanid?

Efavirenz, which lowers pretomanid levels; dolutegravir-based ART is preferred.

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

## Related drugs

- [Bedaquiline](https://durgical.com/en/pharmacology/bedaquiline/)
- [Delamanid](https://durgical.com/en/pharmacology/delamanid/)
- [Moxifloxacin](https://durgical.com/en/pharmacology/moxifloxacin/)
- [Efavirenz](https://durgical.com/en/pharmacology/efavirenz/)

## 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: [WHO consolidated guidelines on tuberculosis: module 4: treatment and care](https://www.who.int/publications/i/item/9789240107243) (World Health Organization (WHO), 2025); [Tuberculosis](https://www.who.int/news-room/fact-sheets/detail/tuberculosis) (World Health Organization (WHO), 2025); [ATCDDD - ATC/DDD Index](https://atcddd.fhi.no/atc_ddd_index/?code=J04AK08) (WHO Collaborating Centre for Drug Statistics Methodology, 2026); Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed., ch. 65 (McGraw Hill, 2023).

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

---
Source: https://durgical.com/en/pharmacology/pretomanid/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/pharmacology/pretomanid/