Abstract
Background: There are some controversies regarding the management of latent tuberculosis infection and tuberculosis in patients with rheumatologic indications for biologic therapy. Objectives: To describe current expert opinions and preferences regarding the evaluation and management of latent tuberculosis infection and tuberculosis in candidates and recipients of tumor-necrosis factor-alpha blocking therapy. Methods: A questionnaire addressing preferences related to management and treatment of latent tuberculosis infection and active tuberculosis in tumor-necrosis factor-alpha blocking candidates was distributed to tuberculosis and rheumatology experts across the United States between August 18, 2009, and June 21, 2010. Survey responses were formulated as a 5-point Likert scale (strongly disagree to strongly agree), or as a priority rank order list (1 to 6 or 7), and data were analyzed for percent agreement and median rankings. Measurements and main results: The tuberculin skin test and interferon-gamma release assays for latent tuberculosis infection screening were highly accepted among tuberculosis and rheumatology experts. Most participants supported the use of daily isoniazid for 9 months for latent tuberculosis infection therapy, but responses were mixed regarding timing to initiation of tumor-necrosis factor-alpha blocking therapy. Most tuberculosis experts supported standard anti-tuberculosis therapy for treatment of tuberculosis, but preferences varied among rheumatologists. In contrast, most rheumatologists believed tumor-necrosis factor-alpha blocking therapy should be stopped in individuals with active tuberculosis, while opinions varied among tuberculosis experts. Conclusions: Agreement among experts was common regarding preferences for diagnosis and management of latent tuberculosis infection and tuberculosis under hypothetical but likely common clinical scenarios, but some differences exist.
Highlights
Inflammatory diseases such as rheumatoid arthritis, inflammatory bowel diseases, and psoriasis are characterized by the deleterious effects of inflammatory cytokines such as tumor-necrosis factor-alpha (TNF-α)
TNF-α blocking (TNFAB) therapy increases the risk for the development of active tuberculosis (TB) and other opportunistic infections, as an effective host immune response against TB relies on Th-1 cytokines, including TNF-α
Several national guidelines have been published, but controversy exists regarding the management of Latent Tuberculosis Infection (LTBI) and TB in patients with rheumatologic indications for biologic therapy
Summary
Inflammatory diseases such as rheumatoid arthritis, inflammatory bowel diseases, and psoriasis are characterized by the deleterious effects of inflammatory cytokines such as tumor-necrosis factor-alpha (TNF-α). While the incidence of TB has been declining in industrialized countries, individuals receiving TNFAB therapy have been found to have higher rates of the disease than the general population or individuals with inflammatory conditions who have not received biologic therapy [2,3]. Despite this well-recognized risk, evidence regarding the prevention and treatment of TB in TNFAB candidates is limited. Several national guidelines have been published, but controversy exists regarding the management of Latent Tuberculosis Infection (LTBI) and TB in patients with rheumatologic indications for biologic therapy. There are some controversies regarding the management of latent tuberculosis infection and tuberculosis in patients with rheumatologic indications for biologic therapy
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