Prevention of Tuberculosis among Patients with Inflammatory Rheumatic Diseases receiving Tumor Necrosis Factor‐α Inhibitors

Review Article


Anand N Malaviya
Affiliation: Rheumatology Services, ISIC Superspeciality Hospital, Vasant Kunj, New Delhi, India


ABSTRACT

High therapeutic efficacy of inhibitors of tumor necrosis factor‐α (iTNF‐α) in the treatment of rheumatoid arthritis (RA), ankylosing spondylitis (AS)–spondyloarthritides (SpA), and several other inflammatory rheumatic diseases (IRDs) has been well established over the past decade. Large registries on the use of these biologicals and extensive experience with their use worldwide have shown that overall these agents have a good safety profile with a highly favorable risk–benefit ratio with the exception of the problem of reactivation of tuberculosis infection (TBI) among patients with latent tuberculosis infection (LTBI) with their use. Observational studies have established that the risk of developing TB is several fold higher with monoclonal antibodies against TNF‐α than with soluble TNF‐α receptor fusion protein. It has also been observed that almost all the TB flare seen with iTNF‐α is reactivation of LTBI. Therefore, key to the prevention of TB flare associated with the use of iTNF‐α is detection of LTBI among prospective users of these agents. There is, however, no “gold standard” for the diagnosis of LTBI. Therefore, different strategies for the screening of LTBI and its treatment have been recommended in different regions of the world. This review discusses the problems related to TB screening especially among patients with IRDs who may have an inherent immunocompromised state, outlining the pros and cons of different strategies and the issues related to the treatment of LTBI prior to the use of iTNF‐α agents. The review focuses especially on TB preventive strategies in high‐burden TB regions of the world.

Keywords: Tuberculosis, latent tuberculosis infection (LTBI), latent tuberculosis infection screening (LTBI screening), inflammatory rheumatic diseases, tumor necrosis factor‐α inhibitors
Correspondence: , Flat 2015/B‐2, Vasant Kunj, New Delhi – 110070, India. Tel: (91)‐11‐26130664; Fax: (91)‐11‐26130725; e‐mail: anand_malaviya@yahoo.com