Stringent screening strategy significantly reduces reactivation rates of tuberculosis in patients with inflammatory bowel disease on anti‐TNF therapy in tuberculosis endemic region

Abstract

Background: Anti-tumor necrosis factor (anti-TNF) therapy use in patients with inflammatory bowel disease (IBD) leads to an increased risk of tuberculosis (TB) reactivation despite latent tuberculosis (LTB) screening, especially in TB endemic regions. Aim:We evaluated the effect of stringent screening strategy and LTB prophylaxis on TB reactivation. Methods:We performed an ambispective comparison between patients who received anti-TNF therapy after January 2019 (late cohort) and between Jan 2005 and Jan 2019 (early cohort). Late cohort patients were subjected to stringent screening criteria which included all: history of past TB/recent contact with active TB, chest X-ray, CT (computed tomography) chest, IGRA (interferon-gamma release assay), TST (tuberculin skin test), and if any positive were given chemoprophylaxis. A cohort comparison was done to evaluate for risk reduction of TB following the stringent screening strategy. Results:One hundred seventy-one patients (63: ulcerative colitis/108: Crohn's disease, mean age diagnosis: 28.5 ± 13.4 years, 60% males, median follow-up duration after anti-TNF: 33 months [interquartile range: 23-57 months]) were included.Among the 112 in the early cohort, 29 (26%) underwent complete TB screening, 22 (19.6%) had LTB, 10 (9%) received chemoprophylaxis, and 19 (17%) developed TB. In comparison, in the late cohort, 100% of patients underwent complete TB screening, 26 (44%) had LTB, 23 (39%) received chemoprophylaxis, and only 1(1.7%) developed TB (p < 0.01). On survival analysis, patients in early cohort had a higher probability of TB reactivation compared with the late cohort (HR: 14.52 (95% CI: 1.90-110.61[p = 0.01]) after adjusting for gender, age at anti-TNF initiation, concomitant immunosuppression, anti-TNF doses, and therapy escalation.

Editorial: choosing the optimal screening method for latent TB in patients with IBD commencing anti‐TNF‐therapy—authors' reply

“…We thank Selinger and colleagues for their insightful comments on our paper. 1,2 We fully agree with the points raised by them that the latent TB screening policy should be dependent on the local endemicity, and the difference in TB incidence between high and low endemic areas should direct different screening strategies. This is evident in the studies from India which have shown rates of TB reactivation as high as 11.6% following anti-TNF therapy in patients with inflammatory bowel diseases which is in direct contrast to the British audit, which did not find any case of reactivation in 360 patients.…”

“…We thank Selinger and colleagues for their insightful comments on our paper 1,2 . We fully agree with the points raised by them that the latent TB screening policy should be dependent on the local endemicity, and the difference in TB incidence between high and low endemic areas should direct different screening strategies.…”

“…The author’s declaration of personal and funding interests are unchanged from those in the original article 2 …”

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

“…46 Supporting this, a recent study from India demonstrated that stringent screening for LTBI prior to anti-TNF therapy that includes clinical history, TST, LTBI, CXR and CT chest can significantly mitigate the risk of TB reactivation. 50 In this study by Kumar et al, 50 However, clinical practice varies significantly as this remains an almost evidence-free zone.…”

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

“…Following the first report of this treatment-related complication [1], several scientific societies and international organizations published guidelines for the screening and treatment of LTBI in patients receiving biological treatment [2]. The adherence to these recommendations led to a decrease, but not the complete disappearance, in the number of cases of active TB [3][4][5]. Active TB still occurs, probably due to inadequate compliance with the screening recommendations [6], the limitations of immunodiagnostic tests [7] and the occurrence of de novo infections [4].…”