Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression—risks, screening, diagnosis and management

Abstract

Summary Background One quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune‐based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence. Aim To review the screening, diagnostic practices and medical management of LTBI in patients with IBD. Methods Published literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD. Results Screening for LTBI should be performed proactively and includes assessment of risk factors, an interferon‐gamma releasing assay or tuberculin skin test and chest X‐ray. LTBI treatment in patients with IBD is scenario‐dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD. Conclusions Proactive screening for LTBI is essential in patients with IBD undergoing immune‐suppressing therapy and several therapeutic strategies are available. Reporting of real‐world experience is essential to refining current management recommendations.

Letter: Ozanimod and latent tuberculosis

“…We read with interest the article by Fehily et al 1 It reviewed the available guidelines on latent tuberculosis (LTB) management and risk of reactivation with immunosuppressive therapy used in patients with inflammatory bowel disease (IBD). The authors identified major gaps in evidence especially with newer IBD treatments.…”

Letter: ozanimod and latent tuberculosis—authors' reply

“…To prevent TB reactivation complications, our review recommends proactive screening for LTBI in patients undergoing immunesuppressive therapy. 2 Further, surveillance should be considered if a patient reports a new TB exposure. 2 However, due to lymphocyte migration inhibition, S1P modulators could theoretically affect LTBI testing results.…”

“…2 Further, surveillance should be considered if a patient reports a new TB exposure. 2 However, due to lymphocyte migration inhibition, S1P modulators could theoretically affect LTBI testing results. Reassuringly, in a retrospective case series of 222 MS patients, only 1 of 13 patients on fingolimod returned an equivocal quantiferon gold (QF-Gold) result even though almost all demonstrated lymphopenia.…”

Performance of Screening Strategies for Latent Tuberculosis Infection in Patients with Inflammatory Bowel Disease: Results from the ENEIDA Registry of GETECCU

“…The low sensitivity of LTBI screening tests (tuberculin skin test (TST) and the interferonγ-release assay (IGRA)) when performed under immunosuppressive therapies [7,9] has been posed as one of the potential factors that increase the risk of active TB during anti-TNF treatment. Different strategies have been developed to improve the performance of immunodiagnostic tests.…”

“…Different strategies have been developed to improve the performance of immunodiagnostic tests. Early screening, performed ideally at inflammatory bowel disease (IBD) diagnosis or in the absence of immunosuppressive drugs [9,10], increases its sensitivity for detecting LTBI. Adding a second TST seven to 14 days after a first negative test increases the LTBI diagnostic yield by 5-25% [10][11][12].…”