Recommendations for Screening, Diagnosis, And

Massachusetts Department of Public Health Division of Tuberculosis Prevention and Control 305 South Street, Jamaica Plain, MA - (617) 983-6970

For patients scheduled to receive Tumor Necrosis Factor-alpha (TNF-α) antagonists: * Recommendations for screening, diagnosis, and treatment of latent TB infection and TB disease

 Consider TB disease as a potential cause of febrile or respiratory illness in patients who are immunocompromised, including those receiving, or having received, TNF-α antagonist.  Use published guidelines (1–3) for diagnosis / treatment of latent TB infection (LTBI) / TB disease.  Screen patients for risk factors for M. tuberculosis and test for LTBI before initiating immunosuppressive therapies, including TNF-α antagonists. Risk factors include 1) history of a positive TB skin test (TST), 2) birth in country where TB is endemic (4) or 3) history of any of the following: a) exposure to person with active, infectious TB, b) residence in a congregate setting (e.g., jail or prison, homeless shelter, or chronic-care facility), c) substance abuse, d) health-care employee in settings with TB patients, e) chest radiographic findings consistent with previous TB (1). Screening and Medical Evaluation  For immunocompromised patients (e.g., because of therapy or other medical conditions), interpret TST induration of >5 mm as positive result and evidence of LTBI  Interpret TST induration of <5 mm as negative result, but not necessarily exclusion for LTBI. - Results from control-antigen skin testing (e.g., Candida) do not alter interpretation of negative TST. - Consider treating for LTBI in patients who have negative TST results but whose epidemiologic and clinical circumstances suggest a probability of LTBI.  History, physical exam and chest x-ray before starting treatment for LTBI, in order to exclude TB disease (1,2). Treatment  Start treatment for LTBI before commencing TNF-α antagonist, preferably with 9 months of daily isoniazid (1,2). - Consider postponing TNF-α antagonist therapy until treatment for LTBI / TB completed, or underway for at least 4 weeks. - Consider repeating LTBI treatment for patients treated in the past if there is another risk / exposure identified since previous treatment, or if treatment was 6 months or less.

* Adapted from: MMWR 2004; 53:683 – 686 (Reference 5)

TB Division: 1/05 1 (Over) TNF-α antagonists include the following:

Generic Names Trade Names etanercept Enbrel® imfliximab Remicaide® adalimumab Humira®

References

1. American Thoracic Society/CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000; 49:1-71 (No. RR-6). http://www.cdc.gov/mmwr/PDF/rr/rr4906.pdf

2. CDC. Update: Adverse event data and revised American Thoracic Society/CDC recommendations against the use of rifampin and pyrazinamide for treatment of latent tuberculosis infection—United States, 2003. MMWR 2003; 52:735-739. http://www.cdc.gov/mmwr/PDF/wk/mm5231.pdf

3. CDC. Treatment of tuberculosis: American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003; 52:1-88 (No. RR-11). http://www.cdc.gov/mmwr/PDF/rr/rr5211.pdf

4. Division of Tuberculosis Prevention and Control web page: http://www.mass.gov/dph/cdc/tb

5. CDC. Tuberculosis associated with blocking agents against Tumor Necrosis Factor-alpha. California, 2002 – 2003. MMWR 2004; 53:683-686. http://www.cdc.gov/mmwr/PDF/wk/mm5330.pdf

TB Division: 1/05 2 (Over)