Re-initiation of biologics after the development of tuberculosis under anti-TNF therapy

Dermatology practice updates in mycobacterial disease

Atypical mycobacterial infections are commonly acquired through exposure to water, and tuberculosis remains highly endemic in many parts of the world. In this era of global connection, travel, and immigration, it is more important than ever to maintain a high index of suspicion for infection from cutaneous tuberculosis and atypical mycobacteria. Epidemics related to surgical procedures have been related to inadequate sterilization, as almost 50% of public water supplies harbor mycobacteria. Improved diagnostic techniques for these microbes, including Auramine-Rhodamine staining and rapid detection of mycobacteria and drug susceptibilities through PCR and MALDI-TOF, have improved detection and treatment outcomes. Given an increasing number of patients on immunosuppressive therapies, clinicians must remain vigilant.

(Re-)introduction of TNF antagonists and JAK inhibitors in patients with previous tuberculosis: a systematic review

BACKGROUND

Tuberculosis (TB) is a common complication associated with treatment with tumour necrosis factor (TNF) antagonists and Janus kinase (JAK) inhibitors. However, there is uncertainty about the risk of TB relapse in patients with TB and comorbidities requiring treatment with these agents.

OBJECTIVES

To assess the risk of TB relapse in patients (re-)started on TNF antagonists or JAK inhibitors.

METHODS

Systematic review.

DATA SOURCES

PubMed and Cochrane Library databases until 11 December 2023.

STUDY ELIGIBILITY CRITERIA

Randomized control trials, prospective and retrospective cohort studies, case reports and case series.

PARTICIPANTS

Patients with current or previous TB who were (re-)started on TNF antagonists or JAK inhibitors.

INTERVENTIONS

(Re-)introduction of TNF antagonists and JAK inhibitors.

ASSESSMENT OF RISK OF BIAS

All studies meeting entry criteria were included regardless of quality.

METHODS OF DATA SYNTHESIS

Categorical data are presented as frequencies and percentages. For non-normally distributed aggregated data, we calculated the pooled weighted median with 95% CI. For individual patient data, the median and interquartile range (IQR) were calculated.

RESULTS

Of 5018 articles screened for eligibility, 67 publications reporting on 368 TB patients who (re-)initiated treatment with TNF antagonists for underlying diseases were included. The median age was 42.5 years (95% CI: 40.4-42.5) and the proportion of female patients was 36.6% (n = 74) of patients whose sex was reported. A total of 14 patients (3.8%, 95% CI: 2.1-6.3%) developed TB relapse after a median of 8.5 months (interquartile range, 6.8-14.8 months) following (re-)initiation of anti-TNF treatment. Furthermore, among 251 articles screened for eligibility, 11 reports on TB patients who were (re-)started on JAK inhibitors for underlying diseases were identified. The median age was 62 years (interquartile range, 48.5-68.5 years) and 45.5% (n = 5) were female. Only one patient (9.1%; 95% CI: 0.2-41.3%) had TB reactivation 10 months after starting treatment with ruxolitinib. In addition, 94 patients who were treated with TNF antagonists and two patients temporarily treated with JAK inhibitors for the prevention or treatment of paradoxical reactions were analysed. None of the publications reported microbiological failure or worsening of TB-related symptoms.

CONCLUSIONS

(Re-)initiation of TNF antagonists and JAK inhibitors may be relatively safe in patients with current or previous TB and the need for further treatment of underlying diseases.

Resuming anti-TNF therapy after development of miliary tuberculosis in Behcet's disease-related uveitis: a case report

PURPOSE

There is no consensus concerning restarting anti-tumour necrosis factor (TNF)-α therapy for uveitis after treatment for active tuberculosis (TB). We report a case of Behcet disease (BD) in which treatment with TNF inhibitor was successfully resumed after treatment for miliary TB.

CASE REPORT

A 48-year-old Japanese male was treated for uveitis of unknown aetiology in the left eye at a general ophthalmology clinic. He was referred to Department of Ophthalmology, Tokyo Medical University Hospital because of macula oedema (ME) not responding to prednisolone (PSL) 20 mg. BD was diagnosed based on fluorescein angiographic findings of diffuse retinal vasculitis characteristic of BD, recurrent oral aphthous ulcer, erythema nodosum-like rash in his legs, and HLA-A26 positivity. After a screening test, adalimumab (ADA) was started as steroid-sparing therapy. Eight months after starting ADA, the patient was diagnosed with miliary TB. ADA and PSL were discontinued immediately due to TB. Anti-TB treatment was completed after 6 months based on clinical improvement, although T-SPOT.TB was still positive. Infliximab with isoniazid was started due to relapse of ME, worsened vitreous haze, and worsened visual acuity in his left eye. Subsequently, his ocular symptoms subsided and there was no relapse of TB.

CONCLUSION

This case suggests that in patients with BD who have discontinued anti-TNF therapy due to miliary TB, restarting anti-TNF therapy may be a therapeutic option after TB has been treated appropriately with careful monitoring for relapse.

Latin American consensus recommendations on the risk of infections in people with multiple sclerosis treated with disease modifying drugs

INTRODUCTION

The emergence of several therapeutic options in multiple sclerosis (MS), which significantly modify the immune system functioning, has led to the need for the consideration of additional factors, such as risk of infections, in the decision-making process. The aim of these consensus recommendations was to discuss and perform a practical guide to Latin American neurologists on the risk of infections at diagnosis, follow-up and prior to initiation of DMDs.

METHODS

A panel of Latin American neurologists, experts in demyelinating diseases and dedicated to management and care of MS patients, gathered during 2021 and 2022 to make consensus recommendations on the risk of infections in PwMS treated with DMDs in Latin America. The RAND/UCLA methodology was developed to synthesize the scientific evidence and expert opinions on health care topics and was used for reaching a formal agreement.

RESULTS

Recommendations were established based on relevant published evidence and expert opinion, focusing on: 1- baseline infection disease and vaccination status; 2- opportunistic infections; 3- progressive multifocal leukoencephalopathy; 4- genitourinary system infections; 5- respiratory tract infections; 6- digestive system infections, 7-others local infections and 8- COVID-19.

CONCLUSION

The recommendations of this consensus seek to optimize the care, management and treatment of PwMS in Latin America. The standardized evidence-based care of pwMS infections will allow better outcomes.

Tuberculosis-Related Uveitis in Patients under Anti-TNF-alpha Therapy: A Case Series

Tumor necrosis factor inhibitors (anti-TNF) have emerged as an effective treatment in noninfectious uveitis (NIU). Anti-TNF may increase the predisposition to infectious disease as tuberculosis (TB). TB-related uveitis in the context of an uveitogenic concurrent systemic immune-mediated disease under anti-TNF treatment remain a diagnostic challenge, deserving special focus on this rare context. Retrospective chart review of patients on anti-TNF drugs for systemic immune-mediated diseases that developed a multicentric microbiologically confirmed active TB with concurrent intraocular involvement.Three patients were recorded. Screening for TB before starting anti-TNF resulted negative in two patients. The other patient had received anti-tuberculous treatment in the past. All showed a microbiologically confirmed extraocular TB after unexpected atypical reactivation of the uveitis shifting to chronic granulomatous pattern.Specialists should be aware of TB reactivation, even with previous negative screening, when ocular uveitis signs and activity do not match with the expected pattern in a patient on anti-TNF drugs.

The risk of infection in patients with multiple sclerosis treated with disease-modifying therapies: A Delphi consensus statement

The risk of infection associated with immunomodulatory or immunosuppressive disease-modifying drugs (DMDs) in patients with multiple sclerosis (MS) has been increasingly addressed in recent scientific literature. A modified Delphi consensus process was conducted to develop clinically relevant, evidence-based recommendations to assist physicians with decision-making in relation to the risks of a wide range of infections associated with different DMDs in patients with MS. The current consensus statements, developed by a panel of experts (neurologists, infectious disease specialists, a gynaecologist and a neuroradiologist), address the risk of iatrogenic infections (opportunistic infections, including herpes and cryptococcal infections, candidiasis and listeria; progressive multifocal leukoencephalopathy; human papillomavirus and urinary tract infections; respiratory tract infections and tuberculosis; hepatitis and gastrointestinal infections) in patients with MS treated with different DMDs, as well as prevention strategies and surveillance strategies for the early identification of infections. In the discussion, more recent data emerged in the literature were taken into consideration. Recommended risk reduction and management strategies for infections include screening at diagnosis and before starting a new DMD, prophylaxis where appropriate, monitoring and early diagnosis.

Tuberculosis and Biologic Therapies: Anti-Tumor Necrosis Factor-α and Beyond

Biologic drugs have revolutionized the treatment of certain hematologic, autoimmune, and malignant diseases, but they may place patients at risk for reactivation or acquisition of tuberculosis. This risk is highest with the tumor necrosis factor-alpha (TNF-α) inhibitors. Amongst this class of drugs, the monoclonal antibodies (infliximab, adalimumab, golimumab) and antibody fragment (certolizumab) carry an increased risk compared to the soluble receptor fusion molecule, etanercept. Treatment of latent TB is critical to decrease the risk of reactivation. Data continues to emerge regarding tuberculosis risk associated with novel biologics targeting cytokines involved in tuberculosis control.

Antibody opsonization enhances MAIT cell responsiveness to bacteria via a TNF-dependent mechanism

Mucosal-associated invariant T (MAIT) cells are an abundant human T-cell subset with antimicrobial properties. They can respond to bacteria presented via antigen-presenting cells (APCs) such as macrophages, which present bacterially derived ligands from the riboflavin synthesis pathway on MR1. Moreover, MAIT cells are also highly responsive to cytokines which enhance and even substitute for T-cell receptor-mediated signaling. The mechanisms leading to an efficient presentation of bacteria to MAIT cells by APCs have not been fully elucidated. Here, we showed that the monocytic cell line THP-1 and B cells activated MAIT cells differentially in response to Escherichia coli. THP-1 cells were generally more potent in inducing IFNγ and IFNγ/TNF production by MAIT cells. Furthermore, THP-1, but not B, cells produced TNF upon bacterial stimulation, which in turn supported IFNγ production by MAIT cells. Finally, we addressed the role of antibody-dependent opsonization of bacteria in the activation of MAIT cells using in vitro models. We found that opsonization had a substantial impact on downstream MAIT cell activation by monocytes. This was associated with enhanced activation of monocytes and increased TNF release. Importantly, this TNF acted in concert with other cytokines to drive MAIT cell activation. These data indicate both a significant interaction between adaptive and innate immunity in the response to bacteria, and an important role for TNF in MAIT cell triggering.

Miliary tuberculosis developing during adalimumab treatment for Behçet's disease with uveitis

Tumour necrosis factor-alpha (TNF-α) is a key proinflammatory cytokine in non-infective uveitis (NIU). Adalimumab, an anti-TNF-α monoclonal antibody, is approved for the treatment of severe NIU by the European Medicines Agency. There is a recognised risk of serious infections, including tuberculosis (TB), during anti-TNF-α therapy in systemic immune-mediated diseases. We describe miliary pulmonary TB during adalimumab therapy for severe NIU. To our knowledge, this is the first detailed report of this complication in a patient with uveitis. We present the challenges of managing vision-threatening uveitis during life-threatening infection necessitating withdrawal of adalimumab and oral immunosuppression therapy. Uveitis activity was controlled during anti-TB therapy with oral corticosteroid therapy.

The Safety Profile of Tumor Necrosis Factor Inhibitors in Ankylosing Spondylitis: Are TNF Inhibitors Safer Than We Thought?

Tumor necrosis factor (TNF) inhibitors significantly improved the treatment options for patients with ankylosing spondylitis. Unfortunately, currently, there is no strategy for sustaining remission of the disease with TNF inhibitors; after discontinuation, a high percentage of patients experience flares in a short time. Therefore, up-to-date, long-term use of TNF inhibitors in patients with ankylosing spondylitis remains necessary. For this reason, the issue of the long-term safety of TNF inhibitors in patients with ankylosing spondylitis raises concerns. Although TNF inhibitors are well established in ankylosing spondylitis treatment, the majority of studies on TNF inhibitors' safety have been performed in patients with rheumatoid arthritis. Until recently, there were very few studies of TNF inhibitors' safety in ankylosing spondylitis. Meanwhile, TNF inhibitors appear to have different safety profiles in ankylosing spondylitis and rheumatoid arthritis. In this review, we describe available data on the occurrence of adverse events associated with TNF inhibitor treatment in ankylosing spondylitis, including serious adverse events, infections, serious infections, tuberculosis, opportunistic infections, hepatitis B reactivation, malignancies, laboratory test abnormalities, autoimmune diseases, paradoxical adverse events, and heart failure.

The Immune Mechanisms of Lung Parenchymal Damage in Tuberculosis and the Role of Host-Directed Therapy

Impaired lung function is common in people with a history of tuberculosis. Host-directed therapy added to tuberculosis treatment may reduce lung damage and result in improved lung function. An understanding of the pathogenesis of pulmonary damage in TB is fundamental to successfully predicting which interventions could be beneficial. In this review, we describe the different features of TB immunopathology that lead to impaired lung function, namely cavities, bronchiectasis, and fibrosis. We discuss the immunological processes that cause lung damage, focusing on studies performed in humans, and using chest radiograph abnormalities as a marker for pulmonary damage. We highlight the roles of matrix metalloproteinases, neutrophils, eicosanoids and cytokines, like tumor necrosis factor-α and interleukin 1β, as well as the role of HIV co-infection. Finally, we focus on various existing drugs that affect one or more of the immunological mediators of lung damage and could therefore play a role as host-directed therapy.

Risk of serious infections in biological treatment of patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a meta-analysis

The objective of the study is to quantitatively assess the risk of serious infections in patients with axial spondyloarthritis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) treated by biologics enrolled in randomized controlled trials (RCTs). A systematic literature searches of MEDLINE (via PubMed), EMBASE, the Cochrane Library and abstracts archives of the annual scientific meetings of both the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) was conducted through October 2015. The RCTs that compared the safety of any biologics treatment for AS or nr-axSpA with placebo and/or non-steroidal anti-inflammatory drugs (NSAIDs) and/or conventional disease modifying antirheumatic drugs (DMARDs) with a minimum of 12 weeks of follow-up were selected independently by 2 reviewers. Twenty-five RCTs with data from 2403 patients were analyzed in the analysis. Patients included active AS in 21 studies and nr-axSpA in 4 studies were treated by 5 TNF inhibitors (adalimumab, certolizumab, etanercept, golimumab and infliximab) and 3 non-TNF inhibitors (sarilumab, tocilizumab, secukinumab). The risk of serious infections has no difference and numerically was only slightly increased in patients with AS and nr-axSpA treated by biologics compared with controls (OR = 1.42; 95%CI 0.58-3.47). Stratified analysis yielded the pooled risk differences (RDs) of 0.00 (95%CI, - 0.01 to 0.01), 0.01 (95%CI - 0.01 to 0.03), - 0.00 (95%CI -0.01 to 0.01), 0.00 (95%CI - 0.02 to 0.02), 0.01 (95%CI -0.01 to 0.03) and 0.01 (95%CI -0.02 to 0.04) for adalimumab, certolizumab, etanercept, golimumab, infliximab and non-TNF inhibitors respectively. There are also no significant effect of biologics on serious infections was observed compared with controls in patients with AS (p = 0.29) and nr-axSpA (p = 0.89). The use of biologics among patients with AS and nr-axSpA included in RCTs was not significantly associated with an increased risk of serious infections compared with placebo or NSAIDs or DMARDs.

Biologic Agents and Tuberculosis

Treatment with biologic agents, in particular tumor necrosis factor alpha (TNF-α) inhibitors, is associated with an increased risk of tuberculosis (TB), and screening and treatment for latent TB infection (LTBI) in patients undergoing such treatment is therefore indicated. The risk of TB associated with different biologics varies significantly, with the highest relative risks, 29.3 and 18.6, associated with adalimumab and infliximab, respectively. The risk of TB with newer TNF-α inhibitors and other biologics appears to be lower. Performance of LTBI screening tests is affected by immune-mediated inflammatory diseases and immunosuppressive therapy in patients due to commence TNF-α inhibitor treatment. Interferon gamma release assays (IGRAs) have a higher specificity than the tuberculin skin test (TST) in patients with Bacillus Calmette–Guérin (BCG) vaccination and have probably a better sensitivity than TST in immunosuppressed patients. LTBI screening programs prior to commencement of anti-TNF-α treatment significantly reduce the incidence of TB, but the optimal screening algorithm, in particular the question of whether a combination of IGRA and TST or a single test only should be used, is a matter of ongoing debate. Use of TST in combination with IGRA is justified to increase sensitivity. Repeat testing for LTBI should be limited to patients at increased risk of TB. If TB develops during anti-TNF-α treatment, it is more likely to be disseminated and extrapulmonary than are other TB cases. Discontinuation of anti-TNF-α treatment in patients diagnosed with TB is associated with an increased risk of immune reconstitution inflammatory syndrome, which is probably best managed by reintroduction of anti-TNF-α treatment.