Diagnosis and treatment of latent tuberculosis in patients with multiple sclerosis, expert consensus. On behalf of the Colombian Association of Neurology, Committee of Multiple Sclerosis

Abstract

BackgroundMultiple sclerosis is an inflammatory and neurodegenerative demyelinating disease. Current treatment of multiple sclerosis focuses on the use of immunomodulatory, immunosuppressant, and selective immunosuppressant agents. Some of these medications may result in high risk of opportunistic infections including tuberculosis.ObjectiveThe purpose of this study was to obtain consensus from a panel of neurologists, pulmonologists, infectious disease specialists, and epidemiology experts regarding the diagnosis, treatment, and monitoring of latent tuberculosis in patients with multiple sclerosis.MethodsA panel of experts in multiple sclerosis and tuberculosis was established. The methodological process was performed in three phases: definition of questions, answer using Delphi methodology, and the discussion of questions not agreed.ResultsTuberculosis screening is suggested when multiple sclerosis drugs are prescribed. The recommended tests for latent tuberculosis are tuberculin and interferon gamma release test. When an anti-tuberculosis treatment is indicated, monitoring should be performed to determine liver enzyme values with consideration of age as well as comorbid conditions such as a history of alcoholism, age, obesity, concomitant hepatotoxic drugs, and history of liver disease.ConclusionLatent tuberculosis should be considered in patients with multiple sclerosis who are going to be treated with immunomodulatory and immunosuppressant medications. Transaminase level monitoring is required on a periodic basis depending on clinical and laboratory characteristics. In addition to the liver impairment, other side effects should be considered when Isoniazid is prescribed.

Active Pulmonary Tuberculosis Triggered by Interferon Beta-1b Therapy of Multiple Sclerosis: Four Case Reports and a Literature Review

“…For monoclonal antibodies targeting CD20, the risk of reactivation is the lowest because B-cell depletion does not affect cell-mediated immunity [7]. A group of experts, neurologists, and pulmonologists have underlined that screening for latent tuberculosis infection (LTBI) is not required for MS patients treated with IFNβ-1b in low-prevalence countries (TB notification rate of <100 TB cases per million population per year) [24]. In our center, no patient was screened for LTBI before the initiation of the treatment for MS, although our country had a TB global incidence rate of 68 cases/100,000 persons per year during 2018.…”

Reducing infection risk in multiple sclerosis and neuromyelitis optica spectrum disorders: a Brazilian reference center's approach

“…Latent tuberculosis should be screened annually in patients using MS DMDs, except for interferons and glatiramer. 39 42 43 Interferon gamma release tests (IGRAs), such as QuantiFERON, are more accurate than tuberculosis skin tests and BCG vaccination does not interfere with them. A meticulous medical history should be taken aiming to identify previous contact with confirmed cases of tuberculosis.…”

The risk of infections for multiple sclerosis and neuromyelitis optica spectrum disorder disease-modifying treatments: Eighth European Committee for Treatment and Research in Multiple Sclerosis Focused Workshop Review. April 2021

“…This has led local expert panels to issue some recommendations for screening of infections in MS patients planning to start a DMT. 136,140,141 For instance, with respect to latent tuberculosis, which is highly prevalent in Latin America (17%), 142 current consensus recommendations include (1) screening of latent tuberculosis for all patients who are to start a DMT; (2) if screening is positive, patients should undergo specific anti-tuberculous treatment and start DMT only 4–8 weeks after treatment initiation; (3) if screening is negative, patients need to be checked annually for tuberculosis and receive antibiotics if positive. Other opportunistic infections should also be checked when treating patients with DMTs in Latin America, such as paracoccidioidomycosis, caused by Paracoccidioides brasiliensis , an endemic fungus in Latin America, which mainly affects the lungs.…”