“Mitigating tuberculosis reactivation risk in IBD patients on anti-TNF therapy”

Abstract

We have read with great interest the study conducted by Giri et al, which highlighted a high risk of tuberculosis (TB) with anti-TNF therapy in Indian inflammatory bowel disease (IBD) patients, despite being screened negative using a comprehensive screening protocol for latent TB (LTB). This screening protocol involved three tests, including chest X-ray, high-resolution computed tomography (HRCT) of the chest, and TST.We would like to highlight our experience and strategy with regards to mitigating TB activation risk in this group of patients. The rates of TB reactivation are notably high in India, and on the basis of a meta-analysis we emphasized the significance of the local TB burden as a key risk factor for TB development in patients with IBD on anti TNF therapy. This underscores the necessity for a rigorous screening protocol to be implemented in endemic areas such as India. We demonstrated that patients with incomplete TB screening face a significantly higher risk of TB reactivation compared to those with complete screening (HR:3.46,95 %CI:1.24–9.70,p = 0.018). Our approach involved stringent screening, incorporating the use of interferon gamma release assay (IGRA) as well as Tuberculin skin test, along with assessing previous TB history or recent exposure to active TB, doing Chest CT instead of Chest Xray. This rigorous screening method can identify a greater number of individuals with LTB, enabling the administration of chemoprophylaxis to this identified group, which effectively led to drastic decrease in risk of TB reactivation from 17.1 % to1.7 %.The study also highlighted the significance of past history of TB and subtle changes on CT scans, which are often overlooked, leading to reactivation in endemic regions. The present study by the authors has reemphasized need for a stringent and complete LTB screening protocol which can mitigate the risk of TB reactivation in patients with IBD on anti-TNF therapy.