Department of Gastroenterology and Human Nutrition, All India Institute of Medical sciences, New Delhi, India.
Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.
Aliment Pharmacol Ther. 2022 Jun;55(11):1431-1440. doi: 10.1111/apt.16839. Epub 2022 Mar 1.
Anti-tumor necrosis factor (anti-TNF) therapy use in patients with inflammatory bowel disease (IBD) leads to an increased risk of tuberculosis (TB) reactivation despite latent tuberculosis (LTB) screening, especially in TB endemic regions.
We evaluated the effect of stringent screening strategy and LTB prophylaxis on TB reactivation.
We performed an ambispective comparison between patients who received anti-TNF therapy after January 2019 (late cohort) and between Jan 2005 and Jan 2019 (early cohort). Late cohort patients were subjected to stringent screening criteria which included all: history of past TB/recent contact with active TB, chest X-ray, CT (computed tomography) chest, IGRA (interferon-gamma release assay), TST (tuberculin skin test), and if any positive were given chemoprophylaxis. A cohort comparison was done to evaluate for risk reduction of TB following the stringent screening strategy.
One hundred seventy-one patients (63: ulcerative colitis/108: Crohn's disease, mean age diagnosis: 28.5 ± 13.4 years, 60% males, median follow-up duration after anti-TNF: 33 months [interquartile range: 23-57 months]) were included. Among the 112 in the early cohort, 29 (26%) underwent complete TB screening, 22 (19.6%) had LTB, 10 (9%) received chemoprophylaxis, and 19 (17%) developed TB. In comparison, in the late cohort, 100% of patients underwent complete TB screening, 26 (44%) had LTB, 23 (39%) received chemoprophylaxis, and only 1(1.7%) developed TB (p < 0.01). On survival analysis, patients in early cohort had a higher probability of TB reactivation compared with the late cohort (HR: 14.52 (95% CI: 1.90-110.61 [p = 0.01]) after adjusting for gender, age at anti-TNF initiation, concomitant immunosuppression, anti-TNF doses, and therapy escalation.
The high risk of TB reactivation with anti-TNF therapy in TB endemic regions can be significantly mitigated with stringent LTB screening and chemoprophylaxis.
尽管进行了潜伏性结核病（LTB）筛查，但在炎症性肠病（IBD）患者中使用抗肿瘤坏死因子（anti-TNF）治疗会增加结核分枝杆菌（TB）再激活的风险，尤其是在结核病流行地区。
我们评估严格的筛查策略和 LTB 预防对 TB 再激活的影响。
我们对 2019 年 1 月后接受抗 TNF 治疗的患者（晚期队列）和 2005 年 1 月至 2019 年 1 月间接受治疗的患者（早期队列）进行了前瞻性比较。晚期队列患者接受了严格的筛查标准，包括所有：既往 TB 病史/近期与活动性 TB 接触史、胸部 X 线检查、胸部 CT 检查、IGRA（干扰素-γ释放试验）、TST（结核菌素皮肤试验），如果任何一项阳性，均给予化学预防。进行队列比较以评估严格的筛查策略对降低 TB 风险的效果。
共纳入 171 例患者（溃疡性结肠炎 63 例，克罗恩病 108 例，平均诊断年龄 28.5±13.4 岁，男性占 60%，抗 TNF 治疗后中位随访时间 33 个月[四分位距：23-57 个月]）。在早期队列的 112 例患者中，29 例（26%）接受了完整的 TB 筛查，22 例（19.6%）有 LTB，10 例（9%）接受了化学预防，19 例（17%）发生了 TB。相比之下，在晚期队列中，100%的患者接受了完整的 TB 筛查，26 例（44%）有 LTB，23 例（39%）接受了化学预防，只有 1 例（1.7%）发生了 TB（p<0.01）。在生存分析中，调整性别、抗 TNF 治疗开始时的年龄、同时使用免疫抑制剂、抗 TNF 剂量和治疗升级后，早期队列患者的 TB 再激活概率高于晚期队列（HR：14.52（95%CI：1.90-110.61[ p=0.01]））。
在结核病流行地区，使用抗 TNF 治疗时，TB 再激活的风险很高，但通过严格的 LTB 筛查和化学预防可以显著降低这种风险。
