Download References - New England TB Consortium

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
etanercept
imfliximab
adalimumab
Trade Names
Enbrel®
Remicaide®
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)