Screening of Latent Tuberculous Infection (LTBI) before Starting Anti-Tumor Necrosis Factor Therapy in Patients with Psoriasis: A Primer for Clinical Dermatologist

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Abstract

Anti-tumor necrosis agents are being increasingly used in the management of moderate to severe psoriasis. Therapy with antitumor necrosis factor alpha (TNF-α) agents is being fraught with reactivation of latent tuberculosis infection (LTBI). This paper addresses the intricate relation between LTBI and anti-TNF-α agents and provides working guidelines for screening of LTBI and its management before prescribing anti-TNF-α therapy in patients with psoriasis.

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Most cited references 32

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Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update.

Madhukar Pai, Alice Zwerling, Dick Menzies (2008)

Interferon-gamma-release assays (IGRAs) are alternatives to the tuberculin skin test (TST). A recent meta-analysis showed that IGRAs have high specificity, even among populations that have received bacille Calmette-Guérin (BCG) vaccination. Sensitivity was suboptimal for TST and IGRAs. To incorporate newly reported evidence from 20 studies into an updated meta-analysis on the sensitivity and specificity of IGRAs. PubMed was searched through 31 March 2008, and citations of all original articles, guidelines, and reviews for studies published in English were reviewed. Studies that evaluated QuantiFERON-TB Gold, QuantiFERON-TB Gold In-Tube (both from Cellestis, Victoria, Australia), and T-SPOT.TB (Oxford Immunotec, Oxford, United Kingdom) or its precommercial ELISpot version, when data on the commercial version were lacking. For assessing sensitivity, the study sample had to have microbiologically confirmed active tuberculosis. For assessing specificity, the sample had to comprise healthy, low-risk individuals without known exposure to tuberculosis. Studies with fewer than 10 participants and those that included only immunocompromised participants were excluded. One reviewer abstracted data on participant characteristics, test characteristics, and test performance from 38 studies; these data were double-checked by a second reviewer. The original investigators were contacted for additional information when necessary. A fixed-effects meta-analysis with correction for overdispersion was done to pool data within prespecified subgroups. The pooled sensitivity was 78% (95% CI, 73% to 82%) for QuantiFERON-TB Gold, 70% (CI, 63% to 78%) for QuantiFERON-TB Gold In-Tube, and 90% (CI, 86% to 93%) for T-SPOT.TB. The pooled specificity for both QuantiFERON tests was 99% among non-BCG-vaccinated participants (CI, 98% to 100%) and 96% (CI, 94% to 98%) among BCG-vaccinated participants. The pooled specificity of T-SPOT.TB (including its precommercial ELISpot version) was 93% (CI, 86% to 100%). Tuberculin skin test results were heterogeneous, but specificity in non-BCG-vaccinated participants was consistently high (97% [CI, 95% to 99%]). Most studies were small and had limitations, including no gold standard for diagnosing latent tuberculosis and variable TST methods and cutoff values. Data on the specificity of the commercial T-SPOT.TB assay were limited. The IGRAs, especially QuantiFERON-TB Gold and QuantiFERON-TB Gold In-Tube, have excellent specificity that is unaffected by BCG vaccination. Tuberculin skin test specificity is high in non-BCG-vaccinated populations but low and variable in BCG-vaccinated populations. Sensitivity of IGRAs and TST is not consistent across tests and populations, but T-SPOT.TB appears to be more sensitive than both QuantiFERON tests and TST.

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Interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review.

Madhukar Pai, Lee W Riley, John M. Colford (2004)

A major challenge in tuberculosis control is the diagnosis and treatment of latent tuberculosis infection. Until recently, there were no alternatives to the tuberculin skin test (TST) for diagnosing latent tuberculosis. However, an alternative has now emerged in the form of a new in-vitro test: the interferon-gamma assay. We did a systematic review to assess the performance of interferon-gamma assays in the immunodiagnosis of tuberculosis. By searching databases, contacting experts and test manufacturers, we identified 75 relevant studies. The results suggest that interferon-gamma assays that use Mycobacterium tuberculosis-specific region of difference 1 (RD1) antigens (such as early secretory antigenic target 6 and culture filtrate protein 10) may have advantages over the TST, in terms of higher specificity, better correlation with exposure to M tuberculosis, and less cross-reactivity due to BCG vaccination and non-tuberculous mycobacterial infection. However, interferon-gamma assays that use RD1 antigens in isolation may maximise specificity at the cost of sensitivity. Assays that use cocktails of RD1 antigens seem to overcome this problem, and such assays have the highest accuracy. RD1-based interferon-gamma assays can potentially identify those with latent tuberculosis who are at high risk for developing active disease, but this requires confirmation. There is inadequate evidence on the value of interferon-gamma assays in the management of immunocompromised individuals, children, patients with extrapulmonary or non-tuberculous mycobacterial disease, and populations in countries where tuberculosis is endemic. Current evidence suggests that interferon-gamma assays based on cocktails of RD1 antigens have the potential to become useful diagnostic tools. Whether this potential can be realised in practice remains to be confirmed in well designed, long-term studies.

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Treatment of rheumatoid arthritis with tumor necrosis factor inhibitors may predispose to significant increase in tuberculosis risk: a multicenter active-surveillance report.

Juan Gomez-Reino, Loreto Carmona, Vicente Valverde … (2003)

The long-term safety of therapeutic agents that neutralize tumor necrosis factor (TNF) is uncertain. Recent evidence based on spontaneous reporting shows an association with active tuberculosis (TB). We undertook this study to determine and describe the long-term safety of 2 of these agents, infliximab and etanercept, in rheumatic diseases based on a national active-surveillance system following the commercialization of the drugs. We analyzed the safety data actively collected in the BIOBADASER (Base de Datos de Productos Biológicos de la Sociedad Española de Reumatología) database, which was launched in February 2000 by the Spanish Society of Rheumatology. For the estimation of TB risk, the annual incidence rate in patients treated with these agents was compared with the background rate and with the rate in a cohort of patients with rheumatoid arthritis (RA) assembled before the era of anti-TNF treatment. Seventy-one participating centers sent data on 1,578 treatments with infliximab (86%) or etanercept (14%) in 1,540 patients. Drug survival rates (reported as the cumulative percentage of patients still receiving medication) for infliximab and etanercept pooled together were 85% and 81% at 1 year and 2 years, respectively. Instances of discontinuation were essentially due to adverse events. Seventeen cases of TB were found in patients treated with infliximab. The estimated incidence of TB associated with infliximab in RA patients was 1,893 per 100,000 in the year 2000 and 1,113 per 100,000 in the year 2001. These findings represent a significant increased risk compared with background rates. In the first 5 months of 2002, after official guidelines were established for TB prevention in patients treated with biologics, only 1 new TB case was registered (in January). Therapy with infliximab is associated with an increased risk of active TB. Proper measures are needed to prevent and manage this adverse event.

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Author and article information

Journal

Journal ID (nlm-ta): Indian J Dermatol

Journal ID (iso-abbrev): Indian J Dermatol

Journal ID (publisher-id): IJD

Title: Indian Journal of Dermatology

Publisher: Wolters Kluwer - Medknow (India )

ISSN (Print): 0019-5154

ISSN (Electronic): 1998-3611

Publication date (Print): Sep-Oct 2021

Volume: 66

Issue: 5

Pages: 501-507

Affiliations

[1] From the Department of Dermatology, All India Institute of Medical Sciences, Patna, Bihar, India

[1 ] Department of Dermatology, Venereology and Leprosy, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Sawangi Meghe, Wardha, Maharashtra, India

[2 ] Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India

[3 ] Department of Family Medicine, Ochsner Louisiana State University, United States of America

Author notes

Address for correspondence: Dr. Bhushan Madke, Department of Dermatology, Venereology and Leprosy, OPD-19, Jawaharlal Nehru Medical College and AVBR Hospital, Sawangi Meghe, Wardha, Maharashtra 442 001, India. E-mail: drbhushan81@ 123456gmail.com

Article

Publisher ID: IJD-66-501

DOI: 10.4103/ijd.IJD_649_16

PMC ID: 8751712

PubMed ID: 35068505

SO-VID: 0f10e5e3-b7d5-4b96-b17e-b623162b1897

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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Screening of Latent Tuberculous Infection (LTBI) before Starting Anti-Tumor Necrosis Factor Therapy in Patients with Psoriasis: A Primer for Clinical Dermatologist

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Most cited references 32

Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update.

Interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review.

Treatment of rheumatoid arthritis with tumor necrosis factor inhibitors may predispose to significant increase in tuberculosis risk: a multicenter active-surveillance report.

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