GUIDELINES - Israeli association of rheumatology guidelines for the prevention of TB in patients treated with TNF-alpha blockers

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Harefuah. 2007 Mar;146(3):235-7, 244.

[Guidelines of the Israeli association of rheumatology for the

prevention of tuberculosis in patients treated with TNF-alpha

blockers][Article in Hebrew]

Elkayam O, Balbir-Gurman A, Lidgi M, Rahav G, Weiler-Ravel D.

Department of Rheumatology, Tel Aviv Medical Center.

The use of TNFalpha blockers is associated with reactivation of

tuberculosis. The Israeli Association of Rheumatology nominated a

committee to determine guidelines for the prevention of tuberculosis

in patients taking TNFalpha blockers. The risk of reactivation of

tuberculosis is higher with monoclonal antibodies to TNFalpha

(infliximab, adalimumab) in comparison with the soluble receptor of

TNFalpha (etanercept). All patients who are candidates to receive

TNFalpha blockers should be screened for active or latent

tuberculosis. The screening includes: Tuberculin Skin Test (TST),

chest X-ray and a questionnaire about possible exposure to

tuberculosis. Two-step screening should be used as recommended by the

Ministry of Health. The reaction elicited in the second test (if

applied) should be used. In the general population latent tuberculosis

is diagnosed when the TST response is 15 mm. or above; a reaction of

10 mm. or above is positive in populations with a history of definite

or probable exposure to TB and 5 mm. is the threshold for populations

who are immunosuppressed or if chest radiography reveals old

tuberculosis without clear documentation of previous treatment.

Patients with a TST less than 5 mm. should be questioned about prior

exposure to tuberculosis. Latent tuberculosis should be treated with a

9 month course of isoniazid (300mg/d) or a 4 month course of

rifampicin (600mg/d) or for 3 months with a combination of 300 mg.

isoniazid and 600 mg. rifampicin daily. The committee recommends

postponing treatment with TNFalpha blockers until completion of

anti-tuberculosis therapy. If the clinical condition requires the

urgent use of TNFalpha blockers, these may be initiated one month

after starting treatment for latent tuberculosis.

PMID: 17460934

http://www.ncbi.nlm.nih.gov/pubmed/17460934

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