Biological agents and respiratory infections: Causative mechanisms and practice management

Tuberculosis screening prior to anti‐tumor necrosis factor therapy among patients with immune‐mediated inflammatory diseases in Japan: a longitudinal study using a large‐scale health insurance claims database

“…However, caution is needed in this situation because TST/IGRA is insufficiently sensitive in patients with the immunosuppressive conditions that are often present in candidates for anti‐TNF therapy . Moreover, given the higher prevalence of tuberculosis in Japan than in other developed countries, the importance of chest radiography in screening for tuberculosis should never be underestimated …”

“…As of 2012, five drugs, namely infliximab (IFX, approved in 2003), etanercept (ETN, in 2005), adalimumab (ADA, in 2008), golimumab (GLM, in 2011) and certolizumab pegol (CZP, in 2012), have been covered by insurance. All of these agents have been approved for rheumatoid arthritis; IFX and ADA have also been approved for psoriasis, Crohn's disease and ulcerative colitis . In Japan, almost any physician can prescribe anti‐TNF agents to patients with these clinical indications.…”

“…The guidelines of the Japan College of Rheumatology and Japanese Dermatological Association, which were available throughout the study period, recommend: (i) taking a medical history; (ii) tuberculin skin test (TST); and (iii) chest radiography as screening practices for possible LTBI or active tuberculosis infection prior to the initiation of anti‐TNF therapy. TST and chest radiography can be accompanied by or replaced with interferon‐gamma release assays (IGRAs) and chest computed tomography (CT) scans, respectively, as indicated . The guidelines also recommend that patients with a positive screening result and/or with suspected LTBI should start preventive therapy from 3 weeks before administration of an anti‐TNF agent .…”

“…However, the risk of tuberculosis can be reduced substantially by screening prior to initiation of anti‐TNF therapy and administration of preventive therapy to those with LTBI before starting anti‐TNF therapy . Some cohort studies and large‐scale post‐marketing surveys of anti‐TNF agents have shown that after introduction of tuberculosis screening the incidence of tuberculosis decreased to almost the incidence in patients not receiving anti‐TNF therapy …”

“…[8][9][10] Some cohort studies and large-scale post-marketing surveys of anti-TNF agents have shown that after introduction of tuberculosis screening the incidence of tuberculosis decreased to almost the incidence in patients not receiving anti-TNF therapy. [11][12][13] Accordingly, current clinical practice guidelines in various regions and clinical specialties recommend tuberculosis screening prior to initiation of anti-TNF therapy, 8,[14][15][16][17][18][19] and such screening has since likely been consistently performed, at least in specialist facilities. 13,[20][21][22] However, a study from the European Union suggested that physicians did not always conduct tuberculosis screening before starting anti-TNF therapy, 23 which raises concerns about reactivation and outbreak of tuberculosis.…”