Characteristics of tuberculosis in patients with rheumatoid arthritis: a retrospective single-center study

Prevalence of latent tuberculosis before biotherapy initiation in rheumatoid arthritis and spondyloarthritis: data from the Moroccan biotherapy registry

Before the initiation of biotherapy in the treatment of rheumatic diseases, it is highly recommended for the patients to be screened for latent tuberculosis infection (LTBI). The objective of this study is to identify the prevalence of LTBI among patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) before the initiation of biologic therapy in the Moroccan biotherapy registry (RBSMR). A cross sectional study was conducted using the baseline data of the Moroccan biotherapy registry. Tuberculin skin test or IGRA test or both tests were done before starting anti-TNF treatment for screening LTBI. The comparisons between positive and negative LTBI patients according to rheumatic disease were examined using categorical comparisons. 259 patients were included in this study.94 patients had RA and 165 had SpA. The mean age of the RA patients was 50.49 ± 11.82 years with a majority of females (84%). The mean age for the SpA patients was 36 ± 13.7 years with a majority of males (67.3%). The prevalence of LTBI in the RBSMR was 21.6%. This prevalence was at 24.8% in SpA patients, while it was at 15.9% for RA patients. After the comparison between positive and negative LTBI patients according to rheumatic disease, no demographic, clinical, or therapeutic characteristics were statistically associated with LTBI. This study found that in an endemic TB country like Morocco, a high prevalence of patients with SpA and RA had LTBI, and that RA patients had a lower prevalence than SpA patients.

Tuberculosis in Biologic-naïve Patients With Rheumatoid Arthritis: Risk Factors and Tuberculosis Characteristics

OBJECTIVE

To investigate risk factors and characteristics of active tuberculosis (TB) in biologic-naïve patients with rheumatoid arthritis (RA).

METHODS

We conducted a population-based case-control study using the Swedish Rheumatology Quality Register, the National Patient Register, and the Tuberculosis Register to identify RA patients with active TB and matched RA controls without TB between 2001-2014. Clinical data were obtained from medical records. TB risk was estimated as adjusted OR (aOR) with 95% CI using univariate and multivariable logistic regression analyses.

RESULTS

After validation of diagnoses, the study included 31 RA patients with TB and 122 matched RA controls. All except 3 cases had reactivation of latent TB. Pulmonary TB was most prevalent (84%). Ever use of methotrexate was not associated with increased TB risk (aOR 0.8, 95% CI 0.3-2.0), whereas ever treatment with leflunomide (aOR 6.0, 95% CI 1.5-24.7), azathioprine (aOR 3.8, 95% CI 1.1-13.8), and prednisolone (PSL; aOR 2.4, 95% CI 1.0-6.0) was. There were no significant differences between maximum dose of PSL, treatment duration with PSL before TB, or cumulative dose of PSL the year before TB diagnosis between cases and controls. Obstructive pulmonary disease was associated with an increased TB risk (aOR 3.9, 95% CI 1.5-10.7).

CONCLUSION

Several RA-associated factors may contribute to increased TB risk in biologic-naïve patients with RA, making the risk of TB activation difficult to predict in the individual patient. To further decrease TB in patients with RA, the results suggest that screening for latent TB should also be considered in biologic-naïve patients.

Therapeutic issues with, and long-term outcomes of, pulmonary mycobacterial tuberculosis treatment in patients with autoimmune rheumatic diseases

Background

Real-world data on treatment safety and outcome of pulmonary tuberculosis (PTB) in patients with rheumatic diseases (RDs) are scarce. This study explored the therapeutic issues of standard first-line anti-tuberculosis (TB) medication in patients in whom PTB complicated autoimmune RDs.

Methods

Observational, retrospective study was conducted in an intermediate TB burden area, South Korea. We evaluated the safety profile of, and adherence to, standard first-line anti-TB medication in PTB patients with systemic RD and assessed the long-term treatment outcomes, up to 84 months after treatment completion.

Results

We included 37 patients suffering from PTB with RD (case group) and 191 without RD (control group). Rheumatoid arthritis (RA) was the most common RD (24 PTB patients, 64.9%). The frequency of severe adverse drug reactions (ADRs) was significantly higher in the case group than in the control group (36.1% vs. 12.5%, P=0.003). Severe gastrointestinal problems were the most commonly observed ADRs, with a high frequency consistently noted in both groups. Changes in first-line anti-TB medication because of severe ADRs were significantly more frequent in the case group, compared with the control group (19.4% vs. 8.3%, P=0.046). No significant between-group difference was evident in terms of long-term unfavorable outcomes (including relapse and mortality) (5.7% cases vs. 1.2% controls, P=0.146).

Conclusions

Clinicians may encounter difficulties when treating PTB in patients with RD. Despite the favorable long-term outcomes of RD patients, the outcomes of individual patients such as those with systemic lupus erythematosus (SLE) should be interpreted with caution during post-therapy follow-up.

Latent tuberculosis infection in patients with rheumatic diseases

Most people infected by Mycobacterium tuberculosis (Mtb) do not have any signs or disease symptoms, a condition known as latent tuberculosis infection (LTBI). The introduction of biological agents, mainly tumor necrosis factor (TNF) inhibitors, for the treatment of immune-mediated diseases such as Rheumatoid Arthritis (RA) and other rheumatic diseases, increased the risk of reactivation of LTBI, leading to development of active TB. Thus, this review will approach the aspects related to LTBI in patients with rheumatologic diseases, especially those using iTNF drugs. For this purpose it will be considered the definition and prevalence of LTBI, mechanisms associated with diseases and medications in use, criteria for screening, diagnosis and treatment. Considering that reactivation of LTBI accounts for a large proportion of the incidence of active TB, adequate diagnosis and treatment are crucial, especially in high-risk groups such as patients with rheumatologic diseases.