Time to update guidelines on screening for latent tuberculosis infection in dermatologic patients being treated with tumor necrosis factor-alfa inhibitors

Abstract

To the Editor: I appreciated the practical and well-organized CME articles by Chirch et al1Chirch L.M. Cataline P.R. Dieckhaus K.D. Grant-Kels J.M. Proactive infectious disease approach to dermatologic patients who are taking tumor necrosis factor-alfa antagonists: part I. risks associated with tumor necrosis factor-alfa antagonists.J Am Acad Dermatol. 2014; 71 (1.e1-1.e8)Abstract Full Text Full Text PDF Google Scholar, 2Chirch L.M. Cataline P.R. Dieckhaus K.D. Grant-Kels J.M. Proactive infectious disease approach to dermatologic patients who are taking tumor necrosis factor-alfa antagonists: part II: screening for patients on tumor necrosis factor-alfa antagonists.J Am Acad Dermatol. 2014; 71 (11.e1-11.e7)Abstract Full Text Full Text PDF Scopus (5) Google Scholar on assessing the risk factors for and screening of infectious diseases in dermatologic patients who are taking tumor necrosis factor-alfa antagonists. There is one correction and one clarification that I would like to bring to the readers' attention.First, the listed answer for the third question in Part I CME examination (No. JA0714) is incorrect (“A serum quantiFERON may help distinguish between latent and active tuberculosis in a patient who received the BCG vaccine”). The quantiFERON test measures a patient's immune reactivity to Mycobacterium tuberculosis. It cannot distinguish between latent and active tuberculosis (TB) infection in any individual, and only a complete medical evaluation (eg, history, physical examination, chest x-ray, and specimen collections for culture) can determine if a patient has active TB infection. I believe the point the authors were trying to make in this question was that in a person with a history of BCG vaccination, a tuberculin skin test could give a false-positive result and the quantiFERON test would be more reliable.Secondly, the authors recommend that screening for latent TB infection be done at baseline and yearly thereafter, and I would like to call attention to changes in the updated guidelines by the Centers for Disease Control and Prevention (CDC) (2010)3Mazurek G.H. Jereb J. Veron A. et al.IGRA Expert Committee, Centers for Disease Control and Prevention (CDC). Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection—United States, 2010.MMWR Recomm Rep. 2010; 59: 1-25PubMed Google Scholar and the American College of Rheumatology (ACR) (2012).4Singh J.A. Furst D.E. Bharat A. et al.2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis.Arthritis Care Res (Hoboken). 2012; 64: 625-639Crossref PubMed Scopus (1322) Google Scholar Both the CDC and the ACR recommend that annual TB testing be done only in individuals who live, travel, or work in situations where TB exposure is likely while they continue receiving treatment with tumor necrosis factor-alfa antagonists (Table I).Table IRisk factors for Mycobacterium tuberculosis infection•Close contacts of person(s) known or suspected to have ATBI•Foreign-born persons from areas with a high incidence of ATBI (eg, Africa, Asia, Eastern Europe, Latin America, and Russia)•Persons who visit areas with a high prevalence of ATBI, especially if visits are prolonged or frequent•Residents and employees of congregate settings whose clients are at an increased risk for ATBI (eg, correctional facilities, long-term care facilities, and homeless shelters)•Health care workers who serve clients who are at an increased risk for ATBI•Populations defined locally as having an increased incidence of LTBI or ATBI, possibly including medically underserved, low-income populations, or persons who abuse drugs or alcohol•Infants, children, and adolescents exposed to adults who are at an increased risk for LTBI or ATBIPersons with any of these characteristics are considered to be at increased risk for tuberculosis infection compared with persons without these characteristics.ATBI, Active Mycobacterium tuberculosis infection; LTBI, latent Mycobacterium tuberculosis infection. Open table in a new tab A summary of the updated ACR and CDC guidelines are shown in Table I and Fig 1. As the most recent guidelines in the dermatology literature are outdated (National Psoriasis Foundation [2008]5Doherty S.D. VanVoorhees A. Lebwohl M.G. Korman N.D. Young M.S. Hsu S. National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents.J Am Acad Dermatol. 2008; 59: 209-217Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar and American Academy of Dermatology [2008]6Menter A. Gottlieb A. Feldman S.R. et al.Guidelines of care for the management of psoriasis and psoriatic arthritis, section 1: overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics.J Am Acad Dermatol. 2008; 58: 826-850Abstract Full Text Full Text PDF PubMed Scopus (1071) Google Scholar), I suggest it is time to update. To the Editor: I appreciated the practical and well-organized CME articles by Chirch et al1Chirch L.M. Cataline P.R. Dieckhaus K.D. Grant-Kels J.M. Proactive infectious disease approach to dermatologic patients who are taking tumor necrosis factor-alfa antagonists: part I. risks associated with tumor necrosis factor-alfa antagonists.J Am Acad Dermatol. 2014; 71 (1.e1-1.e8)Abstract Full Text Full Text PDF Google Scholar, 2Chirch L.M. Cataline P.R. Dieckhaus K.D. Grant-Kels J.M. Proactive infectious disease approach to dermatologic patients who are taking tumor necrosis factor-alfa antagonists: part II: screening for patients on tumor necrosis factor-alfa antagonists.J Am Acad Dermatol. 2014; 71 (11.e1-11.e7)Abstract Full Text Full Text PDF Scopus (5) Google Scholar on assessing the risk factors for and screening of infectious diseases in dermatologic patients who are taking tumor necrosis factor-alfa antagonists. There is one correction and one clarification that I would like to bring to the readers' attention. First, the listed answer for the third question in Part I CME examination (No. JA0714) is incorrect (“A serum quantiFERON may help distinguish between latent and active tuberculosis in a patient who received the BCG vaccine”). The quantiFERON test measures a patient's immune reactivity to Mycobacterium tuberculosis. It cannot distinguish between latent and active tuberculosis (TB) infection in any individual, and only a complete medical evaluation (eg, history, physical examination, chest x-ray, and specimen collections for culture) can determine if a patient has active TB infection. I believe the point the authors were trying to make in this question was that in a person with a history of BCG vaccination, a tuberculin skin test could give a false-positive result and the quantiFERON test would be more reliable. Secondly, the authors recommend that screening for latent TB infection be done at baseline and yearly thereafter, and I would like to call attention to changes in the updated guidelines by the Centers for Disease Control and Prevention (CDC) (2010)3Mazurek G.H. Jereb J. Veron A. et al.IGRA Expert Committee, Centers for Disease Control and Prevention (CDC). Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection—United States, 2010.MMWR Recomm Rep. 2010; 59: 1-25PubMed Google Scholar and the American College of Rheumatology (ACR) (2012).4Singh J.A. Furst D.E. Bharat A. et al.2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis.Arthritis Care Res (Hoboken). 2012; 64: 625-639Crossref PubMed Scopus (1322) Google Scholar Both the CDC and the ACR recommend that annual TB testing be done only in individuals who live, travel, or work in situations where TB exposure is likely while they continue receiving treatment with tumor necrosis factor-alfa antagonists (Table I). Persons with any of these characteristics are considered to be at increased risk for tuberculosis infection compared with persons without these characteristics. ATBI, Active Mycobacterium tuberculosis infection; LTBI, latent Mycobacterium tuberculosis infection. A summary of the updated ACR and CDC guidelines are shown in Table I and Fig 1. As the most recent guidelines in the dermatology literature are outdated (National Psoriasis Foundation [2008]5Doherty S.D. VanVoorhees A. Lebwohl M.G. Korman N.D. Young M.S. Hsu S. National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents.J Am Acad Dermatol. 2008; 59: 209-217Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar and American Academy of Dermatology [2008]6Menter A. Gottlieb A. Feldman S.R. et al.Guidelines of care for the management of psoriasis and psoriatic arthritis, section 1: overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics.J Am Acad Dermatol. 2008; 58: 826-850Abstract Full Text Full Text PDF PubMed Scopus (1071) Google Scholar), I suggest it is time to update. Proactive infectious disease approach to dermatologic patients who are taking tumor necrosis factor–alfa antagonists: Part I. Risks associated with tumor necrosis factor–alfa antagonistsJournal of the American Academy of DermatologyVol. 71Issue 1PreviewTumor necrosis factor–alfa levels are linked to disease severity in patients with inflammatory conditions, such as psoriasis. Inhibitors of this cytokine are commonly used with significant success in the treatment of such inflammatory disorders. Their use, however, can be plagued by infectious complications. An awareness of potential infections associated with these therapies is critical in order to maximize preventive efforts both before and during therapy. This review provides a guide for dermatologists caring for patients in need of this type of biologic therapy to preemptively address the infectious risks. Full-Text PDF Proactive infectious disease approach to dermatologic patients who are taking tumor necrosis factor–alfa antagonists: Part II. Screening for patients on tumor necrosis factor–alfa antagonistsJournal of the American Academy of DermatologyVol. 71Issue 1PreviewTumor necrosis factor–alfa levels are linked to disease severity in patients with inflammatory conditions, such as psoriasis. Inhibitors of this cytokine are commonly used with significant success in the treatment of such inflammatory disorders. Their use, however, can be plagued by infectious complications. An awareness of potential infections associated with these therapies is critical in order to maximize preventive efforts both before and during therapy. This review provides a guide for dermatologists caring for patients in need of this type of biologic therapy to preemptively address the infectious risks. Full-Text PDF Reply to: “Time to update guidelines on screening for latent tuberculosis infection in dermatologic patients being treated with tumor necrosis factor-alfa inhibitors”Journal of the American Academy of DermatologyVol. 72Issue 4PreviewTo the Editor: We thank Dr Duncan for her astute comments regarding our recent publication. Dr Duncan is correct in her comments about CME question 3. A more accurate choice would have been that “A serum quantiferon can help distinguish a false-positive purified protein derivative resulting from a Bacillus Calmette–Guérin (BCG) vaccine from a true positive.” We concur with her that a chest x-ray and sputum collection are the gold standard for differentiating a latent versus active tuberculosis (TB) infection. Full-Text PDF Reply to: “Time to update guidelines on screening for latent tuberculosis infection in dermatologic patients being treated with tumor necrosis factor-alfa inhibitors”Journal of the American Academy of DermatologyVol. 72Issue 4PreviewTo the Editor: We thank Dr Duncan for her letter. Our recommendations related to tuberculosis monitoring with use of biologic medications are influenced by guidelines from other specialties, such as the American College of Rheumatology (ACR). Therefore, it is important to review the guidelines from other groups for changes and updates. The ACR guidelines regarding tuberculosis monitoring have indeed changed since the publication of our consensus statement in 2008.1 Dr Duncan accurately points out that the ACR now recommends annual monitoring solely for patients who have any Centers for Disease Control and Prevention (CDC)-defined risk factors for latent tuberculosis infection. Full-Text PDF Comment on “Time to update guidelines on screening for latent tuberculosis infection in dermatologic patients being treated with tumor necrosis factor-alfa inhibitors”Journal of the American Academy of DermatologyVol. 73Issue 3PreviewTo the Editor: We would like to thank Dr Duncan1 and Dr Doherty et al2 for their thoughtful considerations for an update to the latent tuberculosis (TB) screening guidelines for patients on tumor necrosis factor (TNF) inhibitors. Both referred to the National Psoriasis Foundation (NPF) (2008) consensus statement, which recommends dermatologists screen for TB before initiation of therapy with any TNF-inhibiting medication and at yearly intervals.3 Also referenced were the American College of Rheumatology (ACR) (2012) and the Centers for Disease Control and Prevention (CDC) (2010) updates to their respective guidelines that differed from the NPF recommendations that recommend annual TB testing only be done in individuals who are considered at increased risk for TB infection. Full-Text PDF