Handa Rohini, Upadhyaya Sundeep, Kapoor Sanjiv, Jois Ramesh, Pandey Bimlesh D, Bhatnagar Anuj K, Khanna Ashwani, Goyal Vishal, Kumar Kamal
Department of Rheumatology, Indraprastha Apollo Hospital, New Delhi, India.
Department of Rheumatology, Indian Spinal Injuries Center, New Delhi, India.
Int J Rheum Dis. 2017 Oct;20(10):1313-1325. doi: 10.1111/1756-185X.13129. Epub 2017 Jul 21.
India has a huge patient burden of rheumatic diseases (RDs) including rheumatoid arthritis. The use of biologics has transformed the treatment paradigm for RD; however, biologic treatment-related infections (especially tuberculosis [TB]) are an area of potential concern for TB-endemic nations like India. Anti-tumor necrosis factor (TNF) therapy impairs the physiological TNF-mediated signaling and may cause reactivation and dissemination of latent TB infection (LTBI). Careful screening is, thus, crucial in RD patients who are about to commence anti-TNF treatment. To date, there is no consensus available for the screening, evaluation and treatment of LTBI as well as on the drug dosage and duration regimen (monotherapy or combination therapy) in the Indian population. An evidence-based algorithm for LTBI screening and management in RD patients undergoing biologic disease-modifying anti-rheumatic drug therapy is suggested in this review for Indian rheumatologists. The proposed algorithm guides physicians through a step-wise screening approach, including medical history, tuberculin skin test, interferon gamma release assay, chest radiograph and management of LTBI with isoniazid therapy or its combination with rifampicin. Further, the provided algorithm can aid the national bodies (such as National TB Control Program) in formulating recommendations for LTBI in this high-risk population.
印度包括类风湿关节炎在内的风湿性疾病（RDs）患者负担沉重。生物制剂的使用改变了RD的治疗模式；然而，生物治疗相关感染（尤其是结核病[TB]）是像印度这样结核病流行国家潜在的关注领域。抗肿瘤坏死因子（TNF）疗法会损害生理上TNF介导的信号传导，并可能导致潜伏性结核感染（LTBI）的重新激活和传播。因此，对于即将开始抗TNF治疗的RD患者，仔细筛查至关重要。迄今为止，在印度人群中，对于LTBI的筛查、评估和治疗以及药物剂量和疗程方案（单药治疗或联合治疗）尚无共识。本综述为印度风湿病学家提出了一种基于证据的算法，用于接受生物改善病情抗风湿药物治疗的RD患者的LTBI筛查和管理。所提出的算法通过逐步筛查方法指导医生，包括病史、结核菌素皮肤试验、干扰素γ释放试验、胸部X线片以及用异烟肼治疗或其与利福平联合治疗LTBI。此外，所提供的算法可以帮助国家机构（如国家结核病控制规划）为这一高危人群制定LTBI相关建议。
