Transcript Anti-TNF agents

INFLUENCE OF REPLACING TUBERCULIN SKIN
TEST WITH
EX VIVO INTERFERON Γ RELEASE ASSAYS ON
DECISION TO
ADMINISTER PROPHYLACTIC
ANTITUBERCULOSIS ANTIBIOTICS
BEFORE ANTI-TNF THERAPY
Xavier Mariette, Gabriel Baron, Florence Tubach, Frédéric Lioté, Bernard Combe,
Corinne Miceli-Richard, René-Marc Flipo, Philippe Goupille, Matthieu Allez,
Dominique Salmon, Dominique Emilie†, Guislaine Carcelain*, Philippe Ravaud*
Ann Rheum Dis 2012;71:1783–1790. doi:10.1136/annrheumdis-2011-200408
R1 최하나
Introduction

Immune mediated inflammatory diseases (IMID)
:anti-TNF agents


Rheumatoid arthritis (RA)

Spondylarthropathies (SpA)

Crohn’s disease (CD)

Psoriasis

Juvenile idiopathic arthritis
Anti-TNF agents

Reactivation of latent tuberculosis infection (LTBI) in patients
previously exposed to TB bacilli.
 Screening for LTBI has been recommended before initiating
treatment with TNF blockers.

For detecting LTBI

Tuberculin skin test (TST)

Requires a return visit for reading the test result

Poor specificity
 Lead to unnecessary treatment with antibiotics with the possible risk
of drug toxicity.

Poor sensitivity : immunosuppressive drug
 Lead to false-negative results, with a subsequent risk of TB
reactivation with anti-TNF therapy

Purpose

To investigate the potential influence in clinical practice of replacing
the TST with the QFT-Gold IT and/or T-SPOT.TB for diagnosis of LTBI
in deciding on prophylactic anti-TB antibiotic therapy before antiTNF therapy in patients with IMID
Methods

Study design


Prospective pragmatic multicentre study
Patients and follow up




Consecutive patients with RA, SpA or CD with an indication for initial
biological treatment with anti-TNF agents
14 rheumatology departments and five gastroenterology departments
from 15 tertiary care hospitals
In accordance with the French recommendations for screening for
LTBI, all patients underwent a clinical examination focused on
questioning about previous contact with TB and a chest x-ray.
For 1 year

Tests studied


TST and a blood sample was taken for QFT-Gold IT and T-SPOT.TB
within 3 days  anti-TNF therapy
Assessment of diagnosis and influence on physician’s
therapeutic decision

According to French recommendations, patients with LTBI require
prophylactic antibiotic treatment
(1) Questioning reveals previous TB without adequate treatment, primary TB
infection without adequate treatment, or previous confirmed close contact with
a patient having pulmonary TB
(2) The chest x-ray shows residual nodular tuberculous lesions ≥1 cm in the
absence of previous adequate TB treatment
(3) Wheals ≥5 mm in diameter on TST.

Replaced TST positivity with IGRA positivity
(at least one positive result for QTF-Gold IT or T-SPOT. TB)

Statistical analysis

SAS 9.1 (SAS Institute, Cary, North California, USA)

p<0.05
RESULTS

Patient characteristics

Outcome and compliance with the planned intervention

Comparison between TST and IGRA results

Comparison between TST and IGRA results

Diagnosis and influence on physician’s decision to administer
antibiotic prophylaxis in patients with LTBI defined by tests
and questioning or chest x-ray

Factors associated with positive TST or IGRA results

Factors associated with indeterminate test results

No factor was associated with an indeterminate IGRA result
(indeterminate QFT-Gold IT or T-SPOT TB result) and, in particular,
neither steroid nor immunosuppressant use.
Conclusion

Replacing TST with IGRA for determining LTBI allowed the
proportion of patients with immunemediated inflammatory
diseases needing prophylactic anti-TB antibiotics before
beginning anti-TNF agents to be reduced by half.