Background/Purpose: We have demonstrated previously that latent tuberculosis infection (LTBI) screening is effective in adult rheumatoid arthritis (RA) patients prior to anti-TNF treatment. One study suggested that prevention of tuberculosis in JIA children receiving etanercept is efficient. However, the short-term evaluation and the absence of data regarding other TNF blockage classes precludes a definitive conclusion, particularly taking into consideration that a recent population-based study reported that tuberculosis (TB) risk is significantly higher in JIA patients. Objectives: To evaluate, in an endemic country, the long-term efficacy of LTBI screening and primary prophylaxis in patients with JIA receiving TNF blockers.

Methods: This was a prospective study that included JIA patients (ILAR classification criteria) regularly followed in the Rheumatology outpatient clinic of a tertiary university hospital of Sao Paulo city, Brazil and who were refractory to non-biologic DMARDs and were eligible to anti-TNF therapy. Patients were evaluated for disease activity before starting TNF inhibitor using Juvenile Arthritis Disease Activity Score (JADAS) (patients <19 years old) or Disease Activity Score 28-Joint Counts (DAS28) (patients ≥19 years old). All patients were screened for LTBI prior to anti-TNF treatment using the tuberculin skin test (TST), chest X-ray and history of exposure to TB. When indicated computerized chest tomography was performed. All subjects were regularly followed at 1- to 3-month intervals.

Results: Sixty-nine JIA patients were included and all patients were vaccinated with BCG during neonatal period. They had current age of 17.4 ± 5.8 years, 24 (34.8%) were males and the mean disease duration until anti-TNF initiation was 5.0 ± 4.9 years. Sixty-three (91.3%) patients were under NSAIDs, 31 (44.9%) prednisone, 60 (86.9%) methotrexate, 23 (33.3%) leflunomide and 13 (18.8%) cyclosporine. At baseline, JADAS was 13.4 ± 8.4 and DAS28 3.8 (1.9-6.1). Forty-seven (68.1%) patients were treated with a single anti-TNF agent, while 22 (31.9%) patients switched to another anti-TNF agent once or twice. At the end of follow-up, 33 (47.8%) patients had received adalimumab, 57 (82.6%) etanercept and 3 (4.3%) infliximab. LTBI screening was positive in three (4.3%) JIA patients: one had TST-positive and history of TB exposure and two had solely TST-positive. During follow-up, TST was repeated in two patients due to a long period (> 1 year) of anti-TNF interruption, and TST conversion was observed in one of them. LTBI patients were treated with isoniazid (10mg/Kg/day, up to 300mg/day) for 6 months, and none of them had TB. No active TB was diagnosed during the study period (median of follow-up during anti-TNF therapy was 7.9 years).

Conclusion: The frequency of LTBI in middle class JIA was low. Long-term evaluation revealed that LTBI screening and primary prophylaxis before anti-TNF treatment were effective and TST was the most sensitive parameter to identify these patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/long-term-efficacy-of-latent-tuberculosis-infection-screening-in-juvenile-idiopathic-arthritis-patients-prior-to-anti-tnf-treatment-in-an-endemic-area/