强直性脊柱炎和银屑病关节炎：在流行地区重新审视抗肿瘤坏死因子治疗期间潜伏性结核感染的筛查及其随访。
Ankylosing spondylitis and psoriatic arthritis: revisiting screening of latent tuberculosis infection and its follow-up during anti-tumor necrosis factor therapy in an endemic area.
机构信息
Divisao de Reumatologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR.
出版信息
Clinics (Sao Paulo). 2020 Oct 26;75:e1870. doi: 10.6061/clinics/2020/e1870. eCollection 2020.
OBJECTIVES
To retrospectively evaluate the performance and distinctive pattern of latent tuberculosis (TB) infection (LTBI) screening and treatment in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) under anti-tumor necrosis factor (TNF) therapy and determine the relevance of re-exposure and other risk factors for TB development.
METHODS
A total of 135 and 83 patients with AS and PsA, respectively, were evaluated for LTBI treatment before receiving anti-TNF drugs via the tuberculin skin test (TST), chest radiography, and TB exposure history assessment. All subjects were evaluated for TB infection at 3-month intervals.
RESULTS
The patients with AS were more often treated for LTBI than were those with PsA (42% versus 30%, p=0.043). The former also presented a higher frequency of TST positivity (93% versus 64%, p=0.002), although they had a lower frequency of exposure history (18% versus 52%, p=0.027) and previous TB (0.7% versus 6%, p=0.03). During follow-up [median, 5.8 years; interquartile range (1QR), 2.2-9.0 years], 11/218 (5%) patients developed active TB (AS, n=7; PsA, n=4). TB re-exposure was the main cause in seven patients (64%) after 12 months of therapy (median, 21.9 months; IQR, 14.2-42.8 months) and five LTBI-negative patients. TB was identified within the first year in four patients (36.3%) (median, 5.3 months; IQR, 1.2-8.8 months), two of whom were LTBI-positive. There was no difference in the TB-free survival according to the anti-TNF drug type/class; neither synthetic drug nor prednisone use was related to TB occurrence (p>0.05).
CONCLUSION
Known re-exposure is the most critical factor for incident TB cases in spondyloarthritis. There are also some distinct features in AS and PsA LTBI screening, considering the higher frequency of LTBI and TST positivities in patients with AS. Annual risk reassessment taking into consideration these peculiar features and including the TST should be recommended for patients in endemic countries.
目的
回顾性评估接受抗肿瘤坏死因子（TNF）治疗的强直性脊柱炎（AS）和银屑病关节炎（PsA）患者中潜伏性结核感染（LTBI）筛查和治疗的效果和特征模式，并确定再暴露和其他 TB 发病风险因素的相关性。
方法
分别对 135 例 AS 和 83 例 PsA 患者进行 LTBI 治疗评估，通过结核菌素皮肤试验（TST）、胸部 X 线检查和 TB 暴露史评估，在接受抗 TNF 药物治疗前进行。所有患者均每 3 个月评估一次 TB 感染。
结果
AS 患者接受 LTBI 治疗的比例高于 PsA 患者（42%比 30%，p=0.043）。前者的 TST 阳性率也更高（93%比 64%，p=0.002），尽管前者的暴露史频率更低（18%比 52%，p=0.027），既往 TB 病史更少（0.7%比 6%，p=0.03）。在随访期间[中位数，5.8 年；四分位距（IQR），2.2-9.0 年]，11/218（5%）名患者发生活动性 TB（AS 患者 7 例；PsA 患者 4 例）。在 12 个月的治疗后（中位时间，21.9 个月；IQR，14.2-42.8 个月），7 名患者（64%）的主要原因是 TB 再暴露，5 名 LTBI 阴性患者也是如此。4 名患者（36.3%）在第一年发现 TB（中位时间，5.3 个月；IQR，1.2-8.8 个月），其中 2 名患者 LTBI 阳性。根据抗 TNF 药物类型/类别，TB 无进展生存率无差异；合成药物或泼尼松的使用与 TB 发生无关（p>0.05）。
结论
在脊柱关节炎患者中，已知的再暴露是发生 TB 病例的最关键因素。考虑到 AS 患者中 LTBI 和 TST 阳性率较高，AS 和 PsA 的 LTBI 筛查也存在一些明显的特征。对于来自流行地区的患者，建议每年进行风险重新评估，同时考虑到这些特殊特征，并包括 TST。
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