Division of Rheumatology, Hospital of Prato, Italy.
Division of Rheumatology, Hospital of Prato, Italy.
Autoimmun Rev. 2015 Jun;14(6):503-9. doi: 10.1016/j.autrev.2015.01.011. Epub 2015 Jan 21.
Since the introduction of biologics for the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), and psoriasis (Pso) an increased risk of tuberculosis (TB) reactivation in patients with latent tuberculosis infection (LTBI) has been recorded for anti-TNF agents, while a low or absent risk is associated with the non-anti-TNF targeted biologics. To reduce this risk several recommendation sets have been published over time, but in most of them the host-related risk, and the predisposing role to TB reactivation exerted by corticosteroids and by the traditional disease-modifying anti-rheumatic drugs has not been adequately addressed. Moreover, the management of the underlying disease, and the timing of biologic restarting in patients with TB occurrence have been rarely indicated. A multidisciplinary expert panel, the Italian multidisciplinary task force for screening of tuberculosis before and during biologic therapy (SAFEBIO), was constituted, and through a review of the literature, an evidence-based guidance for LTBI detection, identification of the individualized level of risk of TB reactivation, and practical management of patients with TB occurrence was formulated. The literature review confirmed a higher TB risk associated with monoclonal anti-TNF agents, a low risk for soluble receptor etanercept, and a low or absent risk for non-anti-TNF targeted biologics. Considering the TB reactivation risk associated with host demographic and clinical features, and previous or current non-biologic therapies, a low, intermediate, or high TB reactivation risk in the single patient was identified, thus driving the safest biologic choice. Moreover, based on the underlying disease activity measurement and the different TB risk associated with non-biologic and biologic therapies, practical indications for the treatment of RA, PsA, AS, and Pso in patients with TB occurrence, as well as the safest timing of biologic restarting, were provided.
自生物制剂用于治疗类风湿关节炎 (RA)、银屑病关节炎 (PsA)、强直性脊柱炎 (AS) 和银屑病 (Pso) 以来，抗 TNF 药物已记录到潜伏性结核感染 (LTBI) 患者的结核 (TB) 再激活风险增加，而非抗 TNF 靶向生物制剂则风险较低或不存在。为了降低这种风险，随着时间的推移已经发布了几套建议，但在大多数建议中，宿主相关风险以及皮质类固醇和传统疾病修饰抗风湿药物对 TB 再激活的易感性并未得到充分解决。此外，基础疾病的治疗以及发生 TB 时生物制剂重新启动的时机也很少被提及。成立了一个多学科专家小组，即意大利生物治疗前和期间结核病筛查多学科工作组 (SAFEBIO)，通过对文献的审查，制定了 LTBI 检测、TB 再激活个体风险识别以及发生 TB 患者的实际管理的循证指南。文献复习证实，与单克隆抗 TNF 药物相比，TB 风险更高，可溶性受体依那西普风险较低，而非抗 TNF 靶向生物制剂风险较低或不存在。考虑到与宿主人口统计学和临床特征以及既往或当前非生物疗法相关的 TB 再激活风险，确定了单个患者的 TB 再激活低、中或高风险，从而推动了最安全的生物选择。此外，基于基础疾病活动度测量以及非生物和生物疗法相关的不同 TB 风险，为发生 TB 的患者提供了 RA、PsA、AS 和 Pso 的治疗以及生物制剂重新启动的最安全时机的实用建议。
