Session Type: Abstract Submissions (ACR)
Background/Purpose: Anti-TNFα drugs are associated with an increased risk of tuberculosis (TB) and several recommendation sets for latent tubercular infection (LTBI) detection and TB reactivation prevention are available. Primary end-point of present Italian survey was to investigate the behavior of Italian rheumatologists regarding LTBI detection and TB prevention. Secondary end-points were the occurrence of TB reactivation during anti-TNF therapy despite LTBI screening and the association with different anti-TNF agents.
Methods: An anonymous, 24-multiple-response questionnaire was completed by 393 rheumatologists operating in all Italian regions between January and March 2012. The questionnaire encompassed several aspects of clinical practice including the use of different recommendations, the availability of tuberculin skin test (TST) and interferon-gamma release assay (IGRA), the strategies to detect active TB in the case of positive LTBI, the type and duration of TB prophylaxis, the number of patients currently treated with anti-TNF at the date of March 31,2012 and the recorded active TB cases over the previous 10 years expressed as total number and divided by the specific anti-TNF drug.
Results: The Italian Society for Rheumatology recommendations were used by 323/393 (82%) rheumatologists, other international sets by 60 (15%) and occasionally by 10 (3%).However, local infectious disease experts were always consulted by 81(21%) and occasionally by 73 (19%). TBST and IGRA were available in 78% and 71% of the centers, respectively. LTBI screening was made using chest radiograph (CR)+TST by 39%, CR+IGRA by 28%, CR+TST+IGRA by 33%. Isoniazid (9-month course) for TB reactivation prevention was employed by 324/393 (83%) of rheumatologists, isoniazid+rifampicin for 4 months by 19/393 (5%), other strategies by 50 (12%). TB prevention was initiated in presence of positive TST by 134 (34%) rheumatologists, positive TST+IGRA by 211 (54%), positive IGRA by 48 (12%). When TB prevention was indicated, anti-TNF was started 1 month later in 63% of the cases, after 3 months in 28%, concomitantly in 9%. Over a 10-year period, 39353 patients (pts) received at least one anti-TNF drug and 317 (0.8%) developed active TB. Active TB occurred during the anti-TB prophylaxis period in 192 (60.6%) p., in 24 (7.6%) after anti-TB therapy withdrawal, and in 101 (31.8%) with negative LTBI screening. Active TB cases distribution by drug was: etanercept 51 (16%), adalimumab 98 (31%), infliximab 137 (43.2%), golimumab 9 (2.8%),certolizumab 8 (2.5%), 14 (4.4%) in pts switched to multiple agents, with a significant lower frequency in pts receiving etanercept compared to those treated with monoclonal anti-TNF (χ2= P<0.001).
Conclusion: The Italian rheumatologist attitude to detect LTBI and to prevent TB reactivation in pts requiring anti-TNF is quite variable despite the availability of multiple sets of recommendations. The elevated number of active TB cases during anti-TB therapy and in pts with negative LTBI screening indicate some defects of these procedures. Confirming other studies, active TB occurrence seems significantly lower in pts receiving etanercept compared to monoclonal anti-TNF drugs.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/latent-tuberculosis-detection-and-tuberculosis-reactivation-in-patients-receiving-anti-tnfa-drugs-a-nationwide-italian-survey/