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Riestra S, Taxonera C, Zabana Y, Carpio D, Beltrán B, Mañosa M, Gutiérrez A, Barreiro-de Acosta M. Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on screening and treatment of tuberculosis infection in patients with inflammatory bowel disease. Gastroenterol Hepatol 2020; 44:51-66. [PMID: 32828562 DOI: 10.1016/j.gastrohep.2020.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
There is evidence that following the recommendations on screening and treatment of tuberculosis infection does not completely prevent the onset of tuberculosis in patients with inflammatory bowel disease. This fact, and the increasing use of new biologics and immunomodulators, has led the Spanish Group Working on Crohn's Disease and Ulcerative Colitis to update their recommendations for the prevention of tuberculosis in patients with inflammatory bowel disease. Diagnostic methods for latent tuberculosis infection, different scenarios in which screening is to be performed, strategies to reduce the risk of tuberculosis once biological treatment is initiated and chemoprophylaxis guidelines for latent tuberculosis infection are reviewed, as well as the management of active tuberculosis during biological treatment. Finally, there is a summary of the current recommendations within the paper and in an algorithm.
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Affiliation(s)
- Sabino Riestra
- Servicio de Aparato Digestivo, Hospital Universitario Central de Asturias e Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España.
| | - Carlos Taxonera
- Servicio de Aparato Digestivo, Hospital Clínico San Carlos e Instituto de Investigación del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Yamile Zabana
- Servicio de Aparato Digestivo, Hospital Universitari Mútua Terrassa, Barcelona, España; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, España
| | - Daniel Carpio
- Servicio de Aparato Digestivo, Complexo Hospitalario Universitario de Pontevedra e Instituto de Investigación Biomédica Galicia Sur (IBI), Pontevedra, España
| | - Belén Beltrán
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, España; Servicio de Aparato Digestivo, Hospital Universitari La Fe, Valencia, España
| | - Míriam Mañosa
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, España; Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas [CIBEREhd], Madrid, España; Servicio de Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, España
| | - Manuel Barreiro-de Acosta
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
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Zaemes J, Kim C. Immune checkpoint inhibitor use and tuberculosis: a systematic review of the literature. Eur J Cancer 2020; 132:168-175. [PMID: 32375103 DOI: 10.1016/j.ejca.2020.03.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/14/2020] [Accepted: 03/18/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND An amassing body of evidence exists to support an association between the use of immune checkpoint inhibitors (ICIs) and the development of tuberculosis (TB). METHODS We performed a systematic review of the literature to assess the nature of this relationship using PubMed, EMBASE and meeting proceedings. RESULTS We have identified 16 patients who developed active TB during immunotherapy. Median age was 61 (range: 49-87). Twelve (75%) were male and 4 (25%) were female. Lung cancer was the most common type of cancer (n = 8), followed by melanoma (n = 3) and head and neck cancer (n = 3). Median time to TB reactivation after initiation of ICI therapy was 6.3 months (range: 1-24 months). Two (13%) patients died of complications of TB (spinal cord compression, GI perforation). TB reactivation in organs (pericardium, bone, liver, and GI track; one each) other than the lungs has been documented. We did not find any cases of TB reactivation that occurred during anti-CTLA-4 therapy. CONCLUSION Findings from our systematic review indicate that PD-(L)1 inhibitors are linked to TB reactivation. TB activation can occur in various organs and TB-related fatalities have been reported. TB screening before starting immunotherapy should be considered in high-risk patient populations. Further research, including prospective studies with patients whose baseline TB status is known, is necessary to better understand the incidence of TB reactivation during ICI therapy and how best to manage TB that develops during immunotherapy.
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Affiliation(s)
- Jacob Zaemes
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Chul Kim
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC, USA.
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Borrás-Blasco J, Cortes X, Fernandez-Martinez S, Casterá E, Antequera B. Legionella pneumophilapneumonia possibly due to ustekinumab therapy in a patient with Crohn’s disease. Am J Health Syst Pharm 2017; 74:209-212. [DOI: 10.2146/ajhp160010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | - Xavier Cortes
- Gastroenterology Section, Internal Medicine Division, Hospital de Sagunto, Sagunto, Spain
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Abstract
ABSTRACT
Treatment with biologic agents, in particular tumor necrosis factor alpha (TNF-α) inhibitors, is associated with an increased risk of tuberculosis (TB), and screening and treatment for latent TB infection (LTBI) in patients undergoing such treatment is therefore indicated. The risk of TB associated with different biologics varies significantly, with the highest relative risks, 29.3 and 18.6, associated with adalimumab and infliximab, respectively. The risk of TB with newer TNF-α inhibitors and other biologics appears to be lower. Performance of LTBI screening tests is affected by immune-mediated inflammatory diseases and immunosuppressive therapy in patients due to commence TNF-α inhibitor treatment. Interferon gamma release assays (IGRAs) have a higher specificity than the tuberculin skin test (TST) in patients with Bacillus Calmette–Guérin (BCG) vaccination and have probably a better sensitivity than TST in immunosuppressed patients. LTBI screening programs prior to commencement of anti-TNF-α treatment significantly reduce the incidence of TB, but the optimal screening algorithm, in particular the question of whether a combination of IGRA and TST or a single test only should be used, is a matter of ongoing debate. Use of TST in combination with IGRA is justified to increase sensitivity. Repeat testing for LTBI should be limited to patients at increased risk of TB. If TB develops during anti-TNF-α treatment, it is more likely to be disseminated and extrapulmonary than are other TB cases. Discontinuation of anti-TNF-α treatment in patients diagnosed with TB is associated with an increased risk of immune reconstitution inflammatory syndrome, which is probably best managed by reintroduction of anti-TNF-α treatment.
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Abitbol Y, Laharie D, Cosnes J, Allez M, Nancey S, Amiot A, Aubourg A, Fumery M, Altwegg R, Michetti P, Chanteloup E, Seksik P, Baudry C, Flamant M, Bouguen G, Stefanescu C, Bourrier A, Bommelaer G, Dib N, Bigard MA, Viennot S, Hébuterne X, Gornet JM, Marteau P, Bouhnik Y, Abitbol V, Nahon S. Negative Screening Does Not Rule Out the Risk of Tuberculosis in Patients with Inflammatory Bowel Disease Undergoing Anti-TNF Treatment: A Descriptive Study on the GETAID Cohort. J Crohns Colitis 2016; 10:1179-85. [PMID: 27402916 DOI: 10.1093/ecco-jcc/jjw129] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/26/2016] [Indexed: 12/13/2022]
Abstract
AIM to describe the characteristics of incident cases of tuberculosis [TB] despite negative TB screening tests, in patients with inflammatory bowel disease [IBD] undergoing anti-TNF treatment, and to identify the risk factors involved. METHODS A retrospective descriptive study was conducted at GETAID centers on all IBD patients undergoing anti-TNF treatment who developed TB even though their initial screening test results were negative. The following data were collected using a standardized anonymous questionnaire: IBD, and TB characteristics and evolution, initial screening methods and results, and time before anti-TNF treatment was restarted. RESULTS A total of 44 IBD patients [including 23 men; median age 37 years] were identified at 20 French and Swiss centers at which TB screening was performed [before starting anti-TNF treatment] based on Tuberculin Skin Tests [n = 25], Interferon Gamma Release Assays [n = 12], or both [n = 7]. The median interval from the start of anti-TNF treatment to TB diagnosis was 14.5 months (interquartile range [IQR] 25-75: 4.9-43.3). Pulmonary TB involvement was observed in 25 [57%] patients, and 40 [91%] had at least one extrapulmonary location. One TB patient died as the result of cardiac tamponade. Mycobacterium tuberculosis exposure was thought to be a possible cause of TB in 14 cases [32%]: 7 patients [including 6 health care workers] were exposed to occupational risks, and 7 had travelled to endemic countries. Biotherapy was restarted on 27 patients after a median period of 11.2 months [IQR 25-75: 4.4-15.2] after TB diagnosis without any recurrence of the infection. CONCLUSION Tuberculosis can occur in IBD patients undergoing anti-TNF treatment, even if their initial screening results were negative. In the present population, TB was mostly extrapulmonary and disseminated. TB screening tests should be repeated on people exposed to occupational risks and/or travelers to endemic countries. Restarting anti-TNF treatment seems to be safe.
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Affiliation(s)
- Yael Abitbol
- Departement of Hepato-Gastroenterology, Centre Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - David Laharie
- Department of Hepato-Gastroenterology, Hôpital Haut-Lévêque, Pessac, France
| | - Jacques Cosnes
- Department of Hepato-Gastroenterology, Hôpital Saint Antoine, Paris, France
| | - Matthieu Allez
- Department of Hepato-Gastroenterology, Hôpital Saint Louis, France
| | - Stéphane Nancey
- Department of Hepato-Gastroenterology Hôpital Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Aurélien Amiot
- Department of Hepato-Gastroenterology, Hôpital Mondor, Créteil, France
| | - Alexandre Aubourg
- Department of Hepato-Gastroenterology, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Mathurin Fumery
- Department of Hepato-Gastroenterology, Hôpital Nord, Amiens, France
| | - Romain Altwegg
- Department of Hepato-Gastroenterology, Hôpital Saint-Eloi, Montpellier, France
| | - Pierre Michetti
- Department of Hepato-Gastroenterology, Hôpital La Source-Beaulieu, Lausanne, Suisse
| | - Elise Chanteloup
- Department of Hepato-Gastroenterology, Hôpital Saint-Joseph, Paris, France
| | - Philippe Seksik
- Department of Hepato-Gastroenterology, Hôpital Saint Antoine, Paris, France
| | - Clotilde Baudry
- Department of Hepato-Gastroenterology, Hôpital Saint Louis, France
| | - Mathurin Flamant
- Department of Hepato-Gastroenterology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Guillaume Bouguen
- Department of Hepato-Gastroenterology, Hôpital Pontchaillou, Rennes, France
| | - Carmen Stefanescu
- Department of Hepato-Gastroenterology, Hôpital Beaujon, Clichy, France
| | - Anne Bourrier
- Department of Hepato-Gastroenterology, Hôpital Saint Antoine, Paris, France
| | - Gilles Bommelaer
- Department of Hepato-Gastroenterology, Hôpital Hôtel Dieu, Clermont Ferrand, France
| | - Nina Dib
- Department of Hepato-Gastroenterology, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Marc André Bigard
- Department of Hepato-Gastroenterology, Hôpital de Brabois, Nancy, France
| | - Stephanie Viennot
- Department of Hepato-Gastroenterology, Hôpital Côte de Nacre, Caen, France
| | - Xavier Hébuterne
- Department of Hepato-Gastroenterology, Hôpital de l'Archet, Nice, France
| | - Jean-Marc Gornet
- Department of Hepato-Gastroenterology, Hôpital Saint Louis, France
| | - Philippe Marteau
- Department of Hepato-Gastroenterology, Hôpital Saint Antoine, Paris, France
| | - Yoram Bouhnik
- Department of Hepato-Gastroenterology, Hôpital Beaujon, Clichy, France
| | - Vered Abitbol
- Department of Hepato-Gastroenterology, Hôpital Cochin, Paris, France
| | - Stéphane Nahon
- Departement of Hepato-Gastroenterology, Centre Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
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