title: Evaluation of screening methods for identification of patients with chronic rheumatological disease requiring tuberculosis chemoprophylaxis prior to commencement of TNF-α antagonist therapy.
abstract: BACKGROUND
  Patients undergoing tumour necrosis factor (TNF)-α antagonist therapy are at increased risk of latent tuberculosis infection (LTBI) reactivation. The aim of this study was to determine the optimum available screening strategy for identifying patients for tuberculosis (TB) chemoprophylaxis.
  
  
  METHODS
  We conducted a prospective observational study of consecutive adults with chronic rheumatological disease referred for LTBI screening prior to commencement of TNF-α antagonist therapy. All patients included had calculation of TB risk according to age, ethnicity and year of UK entry, as described in the 2005 British Thoracic Society (BTS) guidelines and measurement of tuberculin skin test (TST) and T.Spot.TB.
  
  
  RESULTS
  There were 187 patients included in the study, with 157 patients (84%) taking immunosuppressants. 137 patients would require further risk stratification according to the BTS algorithm, with 110 (80.3%) classified as being at low risk of having LTBI. There were 39 patients (35.5%) who were categorised as low risk but were either TST and/or T.Spot positive and would not have received chemoprophylaxis according to the BTS algorithm. Combination of all three methods (risk stratification and/or positive T.Spot and/or positive TST) identified 66 patients out of 137 who would potentially be offered chemoprophylaxis, which was greater than any single test or two-test combination.
  
  
  CONCLUSIONS
  Performing both a TST and T.Spot in patients on immunosuppressants prior to commencement of TNF-α antagonist therapy gives an additional yield of potential LTBI compared with use of risk stratification tables alone. Our results suggest that use of all three screening modalities gives the highest yield of patients potentially requiring chemoprophylaxis.
authors: Chest and Allergy Department, St Mary's Hospital, Imperial College NHS trust, , London, UK.
authors: Aran
authors: A
authors: Singanayagam
authors: Kavina
authors: K
authors: Manalan
authors: Saranya
authors: S
authors: Sridhar
authors: Philip L
authors: PL
authors: Molyneaux
authors: David W
authors: DW
authors: Connell
authors: Peter M
authors: PM
authors: George
authors: Anne
authors: A
authors: Kindelerer
authors: Suranjith
authors: S
authors: Seneviratne
authors: Ajit
authors: A
authors: Lalvani
authors: Melissa
authors: M
authors: Wickremasinghe
authors: Onn Min
authors: OM
authors: Kon
mesh_terms: D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D018890:Chemoprevention; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D055985:Latent Tuberculosis / Q000150:complications / Q000175:diagnosis* / Q000517:prevention & control*; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D011446:Prospective Studies; D012216:Rheumatic Diseases / Q000150:complications / Q000188:drug therapy*; D018570:Risk Assessment; D014374:Tuberculin Test / Q000379:methods*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D006113:United Kingdom
chemical_list: D000995:Antitubercular Agents; D007166:Immunosuppressive Agents; D014409:Tumor Necrosis Factor-alpha
keywords: Tuberculosis
references: Eur Respir J. 2012 Dec;40(6):1443-9
references: 22496326
references: Br J Dermatol. 2013 May;168(5):1012-8
references: 23278714
references: Am J Respir Crit Care Med. 2012 Mar 15;185(6):653-9
references: 22198973
references: Am J Public Health. 1974 Mar;64(3):283-91
references: 4811772
references: Am J Respir Crit Care Med. 2000 Apr;161(4 Pt 2):S221-47
references: 10764341
references: Autoimmun Rev. 2008 Dec;8(2):147-52
references: 18706526
references: Arthritis Rheum. 2005 Jun;52(6):1766-72
references: 15934089
references: Int J Tuberc Lung Dis. 2007 Aug;11(8):934-5;author reply 935
references: 17705966
references: J Acquir Immune Defic Syndr. 2011 Mar 1;56(3):230-8
references: 21239993
references: Ann Rheum Dis. 2008 Jan;67(1):84-90
references: 17644549
references: Eur Respir J. 2010 Nov;36(5):1185-206
references: 20530046
references: Chest. 2010 Apr;137(4):952-68
references: 20022968
references: Thorax. 2013 Mar;68(3):230-9
references: 22693179
references: Int J Tuberc Lung Dis. 2006 Nov;10(11):1192-204
references: 17131776
references: J Rheumatol. 2008 May;35(5):776-81
references: 18398944
references: J Rheumatol. 2009 Mar;36(3):546-51
references: 19228655
references: MMWR Morb Mortal Wkly Rep. 2004 Aug 6;53(30):683-6
references: 15295313
references: Ann Rheum Dis. 2010 Apr;69(4):782-4
references: 20185504
references: Ann Rheum Dis. 2010 Jan;69(1):181-5
references: 19176545
references: Thorax. 2006 Jul;61(7):641; author reply 641
references: 16807395
references: Eur J Clin Microbiol Infect Dis. 2008 Oct;27(10):907-13
references: 18470544
references: Ann Rheum Dis. 2005 Sep;64(9):1360-1
references: 16100342
references: JAMA. 2006 May 17;295(19):2275-85
references: 16705109
references: Curr Opin Rheumatol. 2011 Jul;23(4):377-84
references: 21519268
references: Thorax. 2005 Oct;60(10):800-5
references: 16055611
references: Am J Respir Crit Care Med. 2013 Aug 15;188(4):422-31
references: 23262514
references: Chest. 1991 Feb;99(2):465-71
references: 1824929
references: Ann Rheum Dis. 2003 Aug;62(8):791
references: 12860745
references: N Engl J Med. 2001 Oct 11;345(15):1098-104
references: 11596589
references: N Engl J Med. 2002 Dec 5;347(23):1860-6
references: 12466511
references: AIDS Res Hum Retroviruses. 2012 Sep;28(9):1038-43
references: 22352311
references: Rheumatology (Oxford). 2010 Nov;49(11):2217-9
references: 20837498