Abstract
This study aims to compare the latent tuberculosis infection (LTBI) screening strategy of interferon-gamma release assay (IGRA)-alone and in combination with tuberculin skin tests (TSTs) before the initiation of tumor necrosis factor (TNF) inhibitor treatment in patients with inflammatory arthritis. Between January 2011 and June 2017, we enrolled 476 patients who were followed up for ≥1 year after the TNF inhibitor initiation in a tertiary referral center in South Korea. Inflammatory arthritis comprised rheumatoid arthritis in 266 (55.9%) and ankylosing spondylitis in 210 (44.1%) patients. The following strategies were used for LTBI screening during the study period: (i) from January 2011 to October 2014, the combination of TST and QuantiFERON-TB Gold In-Tube (QFT-GIT); (ii) between November 2014 and February 2015, QFT-GIT-alone and (iii) since March 2015, either the combination of TST and QFT-GIT or QFT-GIT-alone depending on the attending physician's choice. We compared the screening strategies of QFT-GIT alone and in combination with TST. Overall, 338 (71.0%) patients received LTBI screening tests using the combination of TST and QFT-GIT, and 138 (29.0%) received QFT-GIT-alone. In addition, the LTBI tests were positive in 159 (47.0%) of 338 patients using the combination tests, and 43.8% (148/338) required LTBI treatment. Meanwhile, the LTBI tests were positive in 32.6% (45/138) of QFT-GIT-alone patients, and 30.4% (42/138) required LTBI treatment. Among 338 patients who received combination tests, 2 patients developed active tuberculosis within 1 year after the TNF inhibitor initiation. Of patients who received QFT-GIT-alone, no patient developed tuberculosis. In conclusion, among patients who received QFT-GIT-alone, the number of patients who required LTBI treatment declined compared to the TST and QFT-GIT combination, and none developed active tuberculosis within 1 year, suggesting that QFT-GIT-alone could be a potential screening strategy for diagnosing LTBI in patients with inflammatory arthritis in South Korea.
Highlights
Tumor necrosis factor (TNF) inhibitor has been increasingly used in the treatment of inflammatory arthritis, including rheumatoid arthritis (RA) and ankylosing spondylitis (AS), with profound effect [1, 2]
The optimal methods for latent tuberculosis infection (LTBI) screening in patients with inflammatory arthritis remain controversial because no study, to date, has compared various strategies directly [9, 15]
This study aims to compare the screening strategies of interferon-gamma release assay (IGRA)-alone and in combination with TST before the initiation of a TNF inhibitor in patients with inflammatory arthritis in South Korea, where the incidence of tuberculosis is intermediate (80–100/100,000 per year) and bacillus Calmette–Guerin (BCG) vaccination is mandatory at birth [16, 17]
Summary
Tumor necrosis factor (TNF) inhibitor has been increasingly used in the treatment of inflammatory arthritis, including rheumatoid arthritis (RA) and ankylosing spondylitis (AS), with profound effect [1, 2]. Patients treated with TNF inhibitors are at increased risk of developing tuberculosis, predominantly through the reactivation of latent tuberculosis infection (LTBI) [3]. Regarding LTBI screening strategies that use TST and/or IGRA, recommendations from different professional organizations and countries are inconsistent with each other because both tests have their limitations, such as accuracy, false-positive or -negative results according to the bacillus Calmette–Guerin (BCG) vaccination history, immunosuppression, cost, and complexity [6,7,8,9]. The optimal methods for LTBI screening in patients with inflammatory arthritis remain controversial because no study, to date, has compared various strategies directly [9, 15]
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