Zusammenfassung
Aufgrund des erhöhten Tuberkulose- (TB-) Risikos beim Einsatz von Tumor-Nekrose-Faktor- (TNF-)α-Inhibitoren in der Behandlung der rheumatoiden Arthritis und anderer Autoimmunkrankheiten sollte bei allen Patienten vor Anti-TNF-α-Therapie eine aktive Tuberkulose ausgeschlossen werden und ein Screening auf das Vorliegen einer latenten tuberkulösen Infektion (LTBI) erfolgen. Das Screening sollte eine Röntgenthoraxaufnahme, eine sorgfältige Anamnese und die Durchführung eines hochspezifischen Interferon-γ-Tests (IGRA) umfassen. (In Zukunft soll die bisherige Abrechenbarkeit der IGRA-Tests über Analogziffern durch eigene EBM-Ziffern abgelöst werden.) Da sowohl falsch-positive als auch falsch-negative Tuberkulin-Hauttest- (THT-) Ergebnisse in diesen Patientengruppen erwartet werden können, wird der früher durchgeführte THT nur noch in Ausnahmefällen empfohlen. Die Behandlung der LTBI umfasst in aller Regel eine Chemoprävention mit Isoniazid (INH) über 9 Monate.
Abstract
Due to the increased risk of tuberculosis (TB) under treatment with TNF-α inhibitors for rheumatoid arthritis and other autoimmune diseases, precautionary measures are required before initiating TNF-α-inhibitor therapy. Patients should have active TB ruled out and screening for latent TB infection should be performed. The screening should include chest X-ray, complete medical history, and the administration of a highly specific interferon-γ-release assay (IGRA). (In the future, the reimbursement of IGRA tests under an analogue procedure code is expected to be formalized by the application of a code specific to the TB-IGRA procedure.) As tuberculin skin test (TST) results can be expected to be either false-positive or false-negative in these patients, the TST, as commonly performed in the past, is recommended only in exceptional situations. For chemopreventive treatment of latent TB infection (LTBI), isoniazid is usually given for 9 months.
Notes
Ob und inwieweit sich die Rate nichtinterpretierbarer Testergebnisse zwischen den beiden IGRA-Verfahren signifikant unterscheidet, wird in weiteren Vergleichsstudien zu klären sein.
Abbreviations
- BCG:
-
Bacille Calmette-Guérin
- IFN-γ:
-
Interferon-Gamma
- IGRA:
-
„Interferon-Gamma Release Assay“
- LTBI:
-
Latente tuberkulöse Infektion
- MTB:
-
Mycobacterium tuberculosis
- NMT:
-
Nichttuberkulöse Mykobakterien (Umweltmykobakterien)
- RA:
-
Rheumatoide Arthritis
- TB:
-
Tuberkulose
- THT:
-
Tuberkulin-Hauttest
- TNF:
-
Tumor-Nekrose-Faktor
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Interessenkonflikt
Der korrespondierende Autor weist auf folgenden Beziehungen hin: R. Diel hat Vortragshonorare von folgenden Firmen erhalten: Astra Zeneca, Biomerieux, Cellestis Europe, Oxford Immunotec, Sanofi Pasteur MSD. B. Manger gibt Beziehungen zu Abbott (Beratertätigkeit, Vorträge), Wyeth (Beratertätigkeit, Vorträge) und Essex (Beratertätigkeit, Vorträge) an. K. Krüger erhielt Vortragshonorare von den Firmen Abbott, Essex, Roche und Wyeth. Trotz des möglichen Interessenkonflikts ist der Beitrag unabhängig und produktneutral.
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Diel, R., Hauer, B., Loddenkemper, R. et al. Empfehlungen für das Tuberkulose-Screening vor Gabe von TNF-α-Inhibitoren bei rheumatischen Erkrankungen. Z. Rheumatol. 68, 411–416 (2009). https://doi.org/10.1007/s00393-009-0475-x
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DOI: https://doi.org/10.1007/s00393-009-0475-x