Tumour necrosis factor antagonist and tuberculosis in patients with rheumatoid arthritis: An Asian perspective

Authors

  • Kin Wang To,

    Corresponding author
    • Division of Respiratory Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, SAR, China
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  • Juan J Gomez Reino,

    1. Department of Medicine and Rheumatology Unit, Hospital Clínico Universitario, USC, Santiago de Compostela, Spain
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  • Dae Hyun Yoo,

    1. Division of Rheumatology, Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea
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  • Lai Shan Tam

    1. Division of Rheumatology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, SAR, China
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  • The Authors: Dr. KW To is Associate Consultant at the Prince of Wales Hospital, Hong Kong, and Honorary Clinical Assistant Professor in Respiratory Medicine at the Chinese University of Hong Kong with special interest in TB and sleep medicine. Professor Juan J Gomez Reino is Professor of Medicine and Head of the Rheumatology Department at the Hospital Clinico Universitario, Santiago de Compostela, Spain, with special interest in the safety of treatment with biologics. Professor Dae Hyun Yoo is Chairman of the Department of Internal Medicine at Hanyang University Hospital, Seoul, with high interest in the guidelines about TB monitoring among rheumatic diseases patients receiving biologics. Professor LS Tam is a professor in rheumatology at the Chinese University of Hong Kong with special interest in biologics on treatment of rheumatoid arthritis.
  • SERIES EDITORS: CHI CHIU LEUNG, CHRISTOPH LANGE AND YING ZHANG

Correspondence: Kin Wang To, Department of Medicine and Therapeutics, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, Hong Kong SAR, China. Email: tokw617@yahoo.com.hk

Abstract

Rheumatoid arthritis (RA) is a systemic autoimmune disease in which inflammation of the joints is one of the dominant clinical abnormalities resulting in serious morbidity. Over the past decade, tumour necrosis factor (TNF) antagonist has revolutionized the treatment of RA. However, the subsequent increased risk of developing tuberculosis is one of the major drawbacks of this otherwise effective treatment. Latent tuberculosis infection (LTBI) is an asymptomatic form of tuberculosis that is confined by the host's immune system. Active tuberculosis may develop when the immune status weakens. This risk is much higher in patients receiving TNF antagonist. Traditionally, tuberculin skin test (TST) is used to diagnose LTBI. Unfortunately, TST cannot distinguish bacillus Calmette-Guérin (BCG) vaccination from tuberculosis making it difficult to use as a reliable diagnostic tool. In addition, possible anergy and interaction of the altered autoimmune status in rheumatological diseases further complicate the interpretation of TST results. Although interferon-gamma release assay (IGRA) has improved the diagnosis of LTBI in immunocompetent individuals, its respective sensitivity/specificity values are unknown in patients with autoimmune disease due to variable pretest probability and lack of confirmatory test for LTBI. Thus, the use of IGRA for screening LTBI is variable among different countries. This review explores the prevalence of tuberculosis in patients receiving TNF antagonist in countries with different tuberculosis disease burdens and the potential mechanisms for variation in the incidence of tuberculosis with different TNF antagonists, the current practice guidelines for assessing the risk of LTBI in different countries, and the possible solutions for improving diagnosis, monitoring and management of LTBI.

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