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Screening for latent tuberculosis before starting TNF-alpha inhibitors in a population with high BCG vaccination rates

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A Correspondence to this article was published on 03 August 2021

Abstract

It is assumed that in candidates for TNF-alpha inhibitor (TNFi) treatment, tuberculin skin test (TST) may be unreliable, since BCG vaccination causes false positive and drugs cause false negative results, favoring the use of Quantiferon or T-spot assays. However, these tests may not be readily available in all parts of the world. We aimed to determine the reliability of TST with respect to BCG vaccination and drugs in candidates for TNFi treatment, and how isoniazid is tolerated, assuming that the use of TST would result in increased isoniazid use. We included 1031 adult patients who were prescribed a TNFi for the first time. We analysed the association of BCG and drugs with TST and Quantiferon results, the determinants of a positive TST, and evaluated the tolerability of isoniazid. BCG vaccination and male sex were associated with positive TST (OR 3.56, 95% CI 1.98–6.41 and OR 2.54, 95% CI 1.75–3.68, respectively), while prednisolone and azathioprine were associated with negative TST (OR 0.63, 95% CI 0.43–0.91 and OR 0.40, 95% CI 0.11–0.76). Isoniazid was prescribed to 684 (66.3%) patients and had to be discontinued in 12.2% of these before 9 months, most commonly due to hepatotoxicity (44%). One patient developed tuberculosis despite isoniazid use. BCG vaccination may be associated with false positive TST, despite a long time since vaccination in candidates for TNFi treatment. Prednisolone and azathioprine use were associated with negative TST. Despite the high frequency of isoniazid use associated with using TST instead of QTF, isoniazid was generally well tolerated.

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Derived data supporting the findings of this study are available from the corresponding author on request.

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Acknowledgments

We thank Professor Hasan Yazici for critical reading of the manuscript.

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Rheumatology, Istanbul University—Cerrahpasa, Kocamustafapasa, Fatih, Istanbul, 34098, Turkey

    Aysa Hacioglu, Melike Melikoglu, Yesim Ozguler, Sinem Nihal Esatoglu, Serdal Ugurlu, Emire Seyahi, Izzet Fresko, Vedat Hamuryudan, Huri Ozdogan, Sebahattin Yurdakul & Gulen Hatemi

  2. Department of Pulmonary Medicine, Istanbul University—Cerrahpasa, Istanbul, Turkey

    Sermin Borekci

  3. Department of Internal Medicine, Division of Gastroenterology, Istanbul University—Cerrahpasa, Istanbul, Turkey

    Ibrahim Hatemi & Aykut Ferhat Celik

  4. Department of Pulmonary Medicine, Maltepe University - Faculty of Medicine, Istanbul, Turkey

    H. Gul Ongen

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  1. Aysa Hacioglu
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Contributions

AH: contributed to the acquisition and interpretation of the data and drafted the work. YO: performed the statistical analysis. YO, SB, MM, SNE, SU, ES, IF, VH, HO, SY, IH, AFC, GO: contributed to the acquisition of the data and revised the work for intellectual content. GH: contributed to the design of the work, interpretation of the data and revision of the work for intellectual content. All authors read and approved the final version to be published. All co-authors take full responsibility for the integrity of all aspects of the work.

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Correspondence to Gulen Hatemi.

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This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Istanbul University-Cerrahpasa Medical Faculty (date: 02.09.2014, approval number: A-30).

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Hacioglu, A., Borekci, S., Melikoglu, M. et al. Screening for latent tuberculosis before starting TNF-alpha inhibitors in a population with high BCG vaccination rates. Rheumatol Int 42, 1443–1451 (2022). https://doi.org/10.1007/s00296-021-04926-z

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