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    Home > Active Ingredient News > Immunology News > How are rheumatic patients screened for TB infection? List of the 10 Recommendations of the Latest Chinese Consensus Guide Consensus

    How are rheumatic patients screened for TB infection? List of the 10 Recommendations of the Latest Chinese Consensus Guide Consensus

    • Last Update: 2023-01-07
    • Source: Internet
    • Author: User
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    Infection with Mycobacterium tuberculosis can present with both tuberculosis and latent infection with Mycobacterium tuberculosis (LTBI).

    LTBI refers to the presence of a long-term immune response to its antigen after infection, but no clinical tuberculosis, and no evidence
    of clinical etiology or radiographic active tuberculosis.
    A recent multicenter, cross-sectional study in China showed that the standardized prevalence of active tuberculosis in rheumatic disease patients was 882 per 100 000, significantly higher than the prevalence of 15-year-olds (459 per 100,000)
    reported in the fifth national tuberculosis epidemiological sample survey in 2010 ≥ 15 years.
    Other studies have shown that patients with rheumatoid arthritis with LTBI have a 2-10-fold increased risk of developing active tuberculosis compared with the general population, and similar conditions
    are found in patients with psoriatic arthritis.
    In summary, clinicians need to test
    for LTBI in these eligible populations in patients with rheumatic disease, given immunocompromise, increased risk of LTBI, and significantly increased risk of developing active tuberculosis.


    Recently, domestic experts in the field of tuberculosis and rheumatic diseases jointly wrote and released the "Expert Consensus on the Diagnosis and Treatment of Latent Infection with Mycobacterium tuberculosis in Patients with Rheumatic Diseases" (referred to as the consensus).

    Based on the epidemiology, evidence-based medical evidence and clinical research data of rheumatic diseases combined with LTBI in China, 10 recommendations are put forward for clinical reference
    .


    10 consensus opinions


    1.
    For patients with rheumatic diseases who are to be treated with tumor necrosis factor inhibitors (TNFi), routine screening for LTBI (1A)
    is recommended.


    Non-TNFi biologics, such as rituximab, abatacept, anakinra, tocilizumab, etc.
    , have a low
    risk of induced TB activity.
    However, it is worth noting that the drug insert for Abatacept emphasizes that the presence of LTBI
    should be screened before starting Abatacept therapy.


    2.
    Patients using targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs, such as tofacitinib) are recommended for routine screening for LTBI (1B).



    3.
    For those who plan to use medium and large doses of glucocorticoids for a long time, especially those with systemic lupus erythematosus, the use of immunosuppressants, low body mass index, and pulmonary interstitial lesions, it is recommended to screen for LTBI (1C)
    if possible.


    4.
    Patients with rheumatic diseases who need long-term use of anti-rheumatic drugs (such as leflunomide, methotrexate, cyclosporine, cyclophosphamide, mycophenolate mofetil) with high risk of tuberculosis activities, and those with conditions are recommended to screen for LTBI (1D).


    5.
    Patients with rheumatic diseases with a positive induration diameter of ≥ 10mm in tuberculin skin test, or patients who have received immunosuppressive treatment for > 1 month and an average diameter of induration ≥ 5mm in tuberculin skin test, should be vigilant, and those with conditions recommend further improving the γ-interferon release test (2D).


    6.
    For patients with rheumatic diseases, the accuracy of γ-interferon release test is better than that of tuberculin skin test, and it is recommended that patients with rheumatic diseases prioritize the use of γ-interferon release test to screen LTBI(1B).


    7.
    LTBI currently lacks a gold standard for diagnosis, and it is recommended to use a variety of methods for screening when available, such as γ-interferon release test combined with tuberculin skin test (2D).


    When clinical screening for LTBI, a detailed history and relevant symptoms and signs should be collected before LTBI is measured
    .
    Symptom screening mainly includes: cough, sputum production, blood in sputum, hemoptysis, recurrent upper respiratory tract infection symptoms, chest pain, fatigue, night sweats, shortness of breath, loss of appetite, decreased body weight, afternoon low fever, female patients may have irregular menstruation and amenorrhea, and even infertility
    .
    A small number of patients present with acute manifestations such as moderate or high fever and dyspnea
    .
    The main purpose of asking patients about their symptoms is to rule out active tuberculosis and other diseases prior to preventive treatment, and to screen directly if these suspicious findings are not present (Figure 1).



    Fig.
    1 Screening and treatment process of latent infection with Mycobacterium tuberculosis in patients with rheumatic diseases


    8.
    Those who have completed standard anti-tuberculosis therapy within 5 years in the past can not be treated with prophylactic anti-tuberculosis therapy, and it is recommended that such patients prefer non-tumor necrosis factor inhibition (1B)
    when using biological agents.


    9.
    If the condition allows, it is recommended that patients with rheumatic diseases with LTBI be treated with prophylactic anti-tuberculosis for at least 1 month before starting biologics; If the condition urgently requires immediate initiation of biologics, it is recommended to start both biologics and prophylactic antituberculous therapy (2D)
    after adequate risk assessment.


    10.
    Isoniazid and rifampicin can be used in principle as a single or combined regimen, but it is recommended to recommend the use of 3-month isoniazid and rifapentin (3HP) regimen (1A).


    The 3HP regimen is i.
    e.
    isoniazid and rifapentine (isoniazid: 15 mg/kg per week; rifapentin: 750-900 mg per week; Table 1).

    This program is a new recommended program in the world, and its advantages are short course of treatment, high treatment completion rate, and good efficacy, but the disadvantage is that the cost is high
    .


    Table 1 Detailed 3HP solutions



    References: National Clinical Research Center for Infectious Diseases/Shenzhen Third People's Hospital, Peking University Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Chinese Antituberculosis Association, Editorial Board of Chinese Journal of Antituberculosis, Shenzhen Key Laboratory of Inflammatory and Immune Diseases.
    Expert consensus on the diagnosis and treatment of latent infection with Mycobacterium tuberculosis in patients with rheumatic diseases[J].
    Chinese Journal of Antituberculosis, 2022, 44(9): 869-879.
    doi: 10.
    19982/j.
    issn.
    1000-6621.
    20220225

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