[Guidelines of the Israeli association of rheumatology for the prevention of tuberculosis in patients treated with TNF-alpha blockers].
The use of TNFalpha blockers is associated with reactivation of tuberculosis. The Israeli Association of Rheumatology nominated a committee to determine guidelines for the prevention of tuberculosis in patients taking TNFalpha blockers. The risk of reactivation of tuberculosis is higher with monoclonal antibodies to TNFalpha (infliximab, adalimumab) in comparison with the soluble receptor of TNFalpha (etanercept). All patients who are candidates to receive TNFalpha blockers should be screened for active or latent tuberculosis. The screening includes: Tuberculin Skin Test (TST), chest X-ray and a questionnaire about possible exposure to tuberculosis. Two-step screening should be used as recommended by the Ministry of Health. The reaction elicited in the second test (if applied) should be used. In the general population latent tuberculosis is diagnosed when the TST response is 15 mm. or above; a reaction of 10 mm. or above is positive in populations with a history of definite or probable exposure to TB and 5 mm. is the threshold for populations who are immunosuppressed or if chest radiography reveals old tuberculosis without clear documentation of previous treatment. Patients with a TST less than 5 mm. should be questioned about prior exposure to tuberculosis. Latent tuberculosis should be treated with a 9 month course of isoniazid (300mg/d) or a 4 month course of rifampicin (600mg/d) or for 3 months with a combination of 300 mg. isoniazid and 600 mg. rifampicin daily. The committee recommends postponing treatment with TNFalpha blockers until completion of anti-tuberculosis therapy. If the clinical condition requires the urgent use of TNFalpha blockers, these may be initiated one month after starting treatment for latent tuberculosis.
Elkayam
Ori
O
Department of Rheumatology, Tel Aviv Medical Center. oribe14@netvision.net.il
Balbir-Gurman
Alexandra
A
Lidgi
Moshe
M
Rahav
Galia
G
Weiler-Ravel
Daniel
D
D000068879:Adalimumab; D000911:Antibodies, Monoclonal / Q000009:adverse effects*; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents / Q000009:adverse effects*; D000068800:Etanercept; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects*; D000069285:Infliximab; D007557:Israel; D018124:Receptors, Tumor Necrosis Factor; D012219:Rheumatology; D012955:Societies, Medical; D014376:Tuberculosis / Q000517:prevention & control*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept