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The cytokine tumor necrosis factor
(TNF) is important in protecting against TB infection; however TNF suppression
is necessary for treating certain diseases. After the use of TNF inhibitors
began, it was found that the suppression activated latent TB infection. The
instructions for resuming TNF suppression in TB patients for treatment of other
diseases—including arthritis—have not been very clear. The 2012 recommendations
from the American College of Rheumatology announce that biologic therapy may be
resumed after TB treatment. The guidelines from the British Society for
Rheumatology hold that patients may continue on biologics if necessary during
TB treatment, and the Spanish Society of Rheumatology states that there is no
evidence of the optimal time for resumption.
Researchers led by Maria Victoria
Hernández, MD, of the Hospital Clinic of Barcelona, and colleagues conducted a
retrospective study to determine the effects of timing in restarting biologic
therapy for persons receiving TNF treatment. Data were taken from the Spanish
Biologic Therapy Registry, which covered 6,479 patients. By November 2011,
there were 52 cases of active TB. In all cases, biologic treatment was stopped,
and in 27, anti-TNF therapy was resumed before TB treatment was completed. The
27 patients were classified as Group 1, and those who completed TB treatment
before resuming biologic therapy were labeled Group 2. The median time for
resumption of treatment was two months in Group 1 and 12 months in Group 2.
There were 15 women in group 1; the mean age of the group was 57 years, and the
mean disease duration was 19 years. Of the 27 patients, the underlying
diagnosis was rheumatoid arthritis in 14, ankylosing spondylitis in 6,
psoriatic arthritis in 3, juvenile idiopathic arthritis in 2, Behçet’s disease
in 1, and undifferentiated spondyloarthropathy in 1. Of these patients, 20 were
taking infliximab, 3 etanercept, and 4 adalimumab. The median time to
resumption of TNF treatment was 2 months in group 1 and 12 months in group 2.
In all but two patients, good
control was achieved after resuming anti-TNF therapy, and patients remained on
treatment. There was no evidence of relapse in the 27 patients during the
four-year follow up. The researchers conclude that resumption of biologic
therapy may not always need to be deferred; patients being treated with TNF
inhibitors who develop TB may safely reinstitute TNF treatment before they
complete TB treatment.
The study, "When Can Biological
Therapy Be Resumed in Patients with Rheumatic Conditions Who Develop
Tuberculosis Infection During Tumor Necrosis Factor Antagonist Therapy?"
was presented at the 76th annual meeting of the American College of
Rheumatology, November 9–14, 2012, Washington D.C., and was published in the
American College of Rheumatology Abstract Supplement (2012; 64(10
supp.):(S701–S702).
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dedicated to enhancing the quality of life for HIV positive individuals and
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