Dynamic QuantiFERON Response in Psoriasis Patients Taking Long-Term Biologic Therapy

Risk of tuberculosis infection and serial changes in interferon-gamma release assays in elderly patients with psoriasis receiving biologic therapy

Elderly patients constitute a significant proportion of patients with psoriasis. Nonetheless, treatment for older patients is more challenging than that for younger ones. Biologic agents are preferable to other systemic drugs for elderly patients with moderate-to-severe psoriasis owing to their high efficacy and favorable tolerability. However, there are limited data on tuberculosis infection risk in elderly patients with psoriasis receiving biologic therapy. This study aimed to evaluate the risk of active tuberculosis and latent tuberculosis infection, assess the serial interferon-gamma release assay results, and evaluate treatment compliance and adverse effects of latent tuberculosis infection treatment in elderly patients with psoriasis on biologic therapy. In this single-center retrospective study, medical charts of elderly patients (age ≥ 65 years) with psoriasis who were treated with a biologic agent (guselkumab, adalimumab, secukinumab, or ustekinumab) between January 2015 and December 2020 were reviewed. We analyzed the results of chest X-rays and those of whole-blood interferon-gamma release assays performed for latent tuberculosis infection screening at baseline (IGRA0) and subsequently at follow-up after initiating biologic therapy (IGRA1). In total, 90 patients underwent IGRA0; 46 (51.11%) of them had latent tuberculosis infection before starting biologic therapy. Overall, four and two patients experienced seroconversion and active tuberculosis during biologic therapy, respectively. The interferon-gamma release assay reversion rate was 29.1%, and the interferon-gamma level significantly decreased in all patients after latent tuberculosis infection treatment (p = 0.004). Latent tuberculosis infection treatment was well tolerated in elderly patients (completion rate, 100%). The risk of latent tuberculosis infection in elderly patients with psoriasis on biologic therapy was comparable to that previously reported for all age groups. However, the active tuberculosis rate was relatively higher.

TST conversions and systemic interferon-gamma increase after methotrexate introduction in psoriasis patients

Background

Tuberculosis screening in psoriasis patients is complex due to the immunological alterations associated with psoriasis, the presence of comorbidities, and the effect of immunosuppressive treatment. However, it is not established whether the results of screening tests are affected by these factors in psoriasis patients.

Objectives

To determine whether there is a change in the results of the tuberculin skin test (TST) or the interferon-gamma release assay (IGRA) in psoriasis patients living in tuberculosis (TB)-endemic area after 12 weeks of methotrexate (MTX) treatment and to investigate the association of the test results with clinical and inflammatory markers.

Methods

Forty-five patients were selected for a prospective single-arm self-controlled study and followed for at least 18 months. The TST, IGRA, Psoriasis Area and Severity Index (PASI), and inflammatory factors (erythrocyte sedimentation rate (ESR), C-reactive protein, interferon-gamma (IFN-γ), and tumor necrosis factor-alpha levels), were determined before and after 12 weeks of oral 15 mg per week MTX administration and compared. The associations between the IGRA and TST results were verified before and after treatment according to inflammatory factors and clinical characteristics (age, blood glucose, weight, body mass index, disease duration, and PASI).

Results

We collected data on 25 patients who completed the full course of therapy and the follow-up. None of the patients developed TB. TST positivity was significantly elevated at week 12 (25% baseline vs 44% at week 12, P < 0.037). Three IGRAs followed the TST conversions. There was no difference between TST and IGRA pre- or posttreatment. Serum IFN-γ increased significantly in week 12 (15.95 pg/ml baseline vs 18.82 pg/ml at week 12, P < 0.005) and tended to be higher among TST-positive patients (P = 0.072). The baseline IGRA was associated with a higher ESR (P = 0.038). None of the test results were associated with clinical characteristics.

Conclusions

In addition to the classic booster effect, TST conversions in patients using MTX can occur due to an increase in IFN-γ. However, it is not possible to exclude true TST conversions. Therefore, other diagnostic methods, like IGRA or chest tomography, should be used when the TST has intermediate results.

QuantiFERON TB-gold conversion rate among psoriasis patients under biologics: a 9-year retrospective study

BACKGROUND

Tuberculosis (TB) screening is mandatory for psoriasis biologic treatment. However, evidences regarding TB screening results during biologic treatment are conflicting.

OBJECTIVES

The aim of this study is to evaluate the rate of QuantiFERON TB Gold test (QFT) conversion in psoriasis patients during biologics over time.

METHODS

A 9-year single center retrospective study was performed in order to evaluate the rate of QFT conversion in patients affected by moderate-to-severe plaque psoriasis under available biological therapies (anti-TNF-α, IL-12/23, IL-17). For each patient, demographic data, age, gender, comorbidities, previous psoriasis therapy, as well as ongoing treatment type were registered. Five-hundred twenty-six patients (61.2% male, with a mean age of 52.6 ± 13.9 years) treated with biologics were enrolled.

RESULTS

QFT conversion occurred in 6.5% of patients over a mean treatment duration of 3.2 years. On average, QFT conversion occurred after 34.05 months of treatment. Anti-TNF-α drugs, and among them, adalimumab above all (35.5% of all cases), were the most commonly involved treatment during QFT conversion, followed by anti-IL-12/23 (17.6%) and anti-IL-17 (14.7%). However, differences among biologics class or single biologics (adalimumab, etanercept, infliximab, golimumab, certolizumab, ustekinumab, ixekizumab, secukinumab) did not approach statistical significance.

CONCLUSIONS

Annual TB screening is important in psoriasis patients under biologic treatment in order to avoid possible latent TB infection reactivation. Indeed, our data showed that even in a low TB prevalence country like Italy, QFT may convert over time in psoriasis patients under biologics in 6.5% of the cases.

Management of psoriatic patients in biologic treatment associated with infectious comorbidities

Introduction

Psoriasis is a chronic inflammatory disease affecting about 2% of population, involving both acquired and innate immunity. Psoriasis affects mainly skin, presenting multiple co-morbidities; among them infective ones. Re-activation of tuberculosis or viral hepatitis (HBV and HCV) still represents a therapeutic challenge in patients receiving treatment with biological drugs, as well as HIV infection. For this reason, a multidisciplinary approach with global treatment resulting from active collaboration of different specialists is highly recommended.

Aim

To investigate the most common infective diseases as co-morbidities associated with psoriasis and to provide algorithms for screening, follow-up and therapeutic management in psoriatic patients.

Material and methods

We examined the main infectious comorbidities that can affect moderate to severe psoriatic patients, influencing the therapeutic choice as during the biological treatment both viral and tuberculosis re-activation may occur. We have therefore evaluated the main diseases (TB, Hepatitis B and C, HIV) and the monitoring of patients during treatment with biological agents.

Results

Regular monitoring of psoriatic patients is recommended during long-term treatment with biological drugs in order to identify cases of re-activation of the latent infective agent or de novo acquired infection.

Conclusions

Here we report the state of art regarding management of psoriatic patients with these co-morbidities suggesting a specific screening and management for infectious diseases in patients with moderate to severe plaque psoriasis.

Preventive tuberculosis treatment effect on QuantiFERON TB-Gold in-tube testing in a high tuberculosis-endemic country: A clinical trial

BACKGROUND

Whether T-cell interferon-γ responses to Mycobacterium tuberculosis-specific antigens can be influenced by tuberculosis preventive treatment in a high-endemic country is uncertain.

METHODS

In this prospective, open-label, controlled study, 513 individuals with silicosis were randomly selected for TB preventive treatment with rifapentine and isoniazid or for observation. QuantiFERON-TB Gold in-tube (QFT-GIT) assay was used to measure IFN-γ response to M. tuberculosis antigens at baseline (T0) and at 6 (T1) and 33 (T2) months after completion of therapy.

RESULTS

A total of 220 subjects were included in the final analysis: 105 and 115 in the prevention and observation arms, respectively. The proportions of QFT-GIT reversion from baseline to T1 were similar in the prevention and observation arms (18.4% vs 12.8%, P=0.566). However, reversion from baseline to T2 was more frequent in the prevention arm than in the observation arm, but the difference was not significant (24.2% vs 6.3%, P=0.881). No significant difference was observed in the quantitative responses of QFT-GIT between the two arms during follow-up at T1 (P=0.648) and T2 (P=0.918).

CONCLUSIONS

Preventive tuberculosis treatment has no effect on interferon-γ responses measured by serial QFT-GIT assays in a high tuberculosis-endemic country.

CLINICAL TRIALS REGISTRATION

http://www.clinicaltrials.gov NCT02430259.

Challenges in screening for latent tuberculosis in inflammatory bowel disease prior to biologic treatment: a UK cohort study

OBJECTIVE

The aim of this study was to determine the occurrence of latent tuberculosis infections (LTBI) and active TB in a cohort of patients with inflammatory bowel disease (IBD) treated with biologics. We also examined the effects of immunosuppressive drugs on indeterminate interferon-gamma release assays (IGRA) in LTBI screening.

DESIGN

Retrospective study of patients treated with biologics between March 2007 and November 2015.

SETTING

St Mark's Hospital, North West London, UK.

PATIENTS

732 patients with IBD who were screened for LTBI using either tuberculin skin test or IGRA before starting a biologic treatment.

METHODS

Retrospective case note review of all patients with IBD who were screened for LTBI prior to initiating biologics. Patients who developed active TB were identified from the London TB register.

RESULTS

Of 732 patients with IBD, 31 (4.2%) were diagnosed with and treated for LTBI with no significant side effects. Six of 596 patients (1.0%) who received biologic treatment developed active TB. There was a higher proportion of indeterminate IGRA in the immunosuppressive medication group compared with the non-immunosuppressive group (33% (59/181) compared with 9% (6/66), p<0.001). The combination of steroids and thiopurines had the highest proportion of indeterminate IGRA (64%, 16/25). High and low doses of steroids were equally likely to result in an indeterminate IGRA result (67% (8/12) and 57% (4/7), respectively).

CONCLUSIONS

This study highlights the challenges of LTBI screening prior to commencing biologic therapy and demonstrates the risk of TB in patients who have been screened and who are receiving prolonged and continuing doses of antitumour necrosis factor.

Reversion of QuantiFERON-TB Gold In-Tube test in individuals with and without prophylactic treatment for latent tuberculosis infection: A systematic review and meta-analysis

OBJECTIVES

Reversion of tuberculosis (TB) infection testing has been suggested to be associated with prophylactic treatment efficacy. However, evidences based on randomized controlled study were sparse.

METHODS

Studies on serial QuantiFERON-TB Gold In-Tube (QFT) test, among individuals with and without prophylactic treatment were identified in the databases of PubMed, MEDLINE and EMBASE up to 28 February 2018. The reversion rates were quantitatively summarized by means of meta-analysis using the random-effect model.

RESULTS

A total of 52 eligible studies were included in the meta-analysis on QFT test reversion rate among participants with (20 studies) and without (32 studies) prophylactic treatment. Summarized reversion rate was found to be 24.9% (95% confidence interval [CI]: 18.4-32.9%) and 25.3% (95% CI: 19.6-32.0%) for those completed or without treatment, respectively. When the analysis was restricted to the participants completed treatment, higher summarized rate of QFT reversion was found among those with longer course therapy (9INH vs. the other regimens), studies from Asia (vs. Europe and America), and individuals with immunosuppression disorders (vs. general populations).

CONCLUSIONS

Our results suggested that QFT reversion was frequently observed regardless of with or without prophylactic treatment. Serial QFT testing might be inappropriate for evaluating preventive treatment efficacy.

Detecting latent tuberculosis in compromised patients

PURPOSE OF REVIEW

The detection of latent tuberculosis infection (LTBI) in different categories of compromised patients is reviewed with focus on the role of strategies incorporating immunodiagnostic tests and analysis of epidemiological and clinical risk factors.

RECENT FINDINGS

The development of active tuberculosis (TB) is increased in compromised patients and is closely related to determinants for disease reactivation or newly acquired TB infection. A targeted detection of LTBI in these high-risk groups should be performed especially if preventive treatment is planned. The performance of immunodiagnostic tests is highly variable among different groups of immunocompromised individuals. Findings of cross-sectional studies indicate a better diagnostic accuracy of interferon-γ release assays over the tuberculin skin test. The critical issue is that in low-incidence countries, the positive and negative predictive values of any of immunodiagnostic tests were very poor. A targeted testing process involving analysis of TB risk factors increases the predictive positive values of immunodiagnostic tests and may improve LTBI detection.

SUMMARY

The LTBI detection in immunocompromised patients is a challenge. The development of new immunological biomarkers and integrated clinical and epidemiological strategies are needed to identify LTBI in compromised individuals and to plan preventive chemotherapies in those at risk of developing active TB.

Estimation of the prevalence of latent tuberculosis infection in patients with moderate to severe plaque psoriasis in Spain: The Latent study

BACKGROUND AND OBJECTIVE

Anti-tumor necrosis factor therapy for moderate to severe psoriasis can increase the risk of active tuberculosis in patients who have latent tuberculosis infection (LTBI). The main objective of this study was to estimate the prevalence of LTBI in patients with moderate to severe plaque psoriasis being treated in dermatology clinics in Spain.

MATERIAL AND METHOD

Non-interventional, cross-sectional, national epidemiological study conducted in Spain in 2011-2012. Patients with moderate to severe plaque psoriasis were included if they had undergone at least one tuberculin skin test (TST) and/or been evaluated with an interferon-γ release assay (IGRA) based on enzyme-linked immunosorbent assay (QuantiFERON(®) TB Gold In-Tube) in the 2 years preceding the study.

RESULTS

Data for 440 patients were valid for analysis. In total, 97.7% of the patients had undergone a TST, with a positive result in 23%. Of the 238 patients in whom the initial result was negative, 5% converted to positive on re-testing for a booster effect. IGRA results were available for 16.8%, 20.5% of them positive. Two of the patients with positive IGRA results had a negative TST. The prevalence of LTBI in the whole sample was 26.6%. The degree of concordance between the TST and the IGRA was moderate (κ=0.516; P<.001).

CONCLUSIONS

The prevalence of LTBI in this study was similar to previous estimates for Spain.

Diagnosis of tuberculosis infection by interferon-gamma release assays in patients with psoriasis

OBJECTIVE

In this study, we have performed a direct comparison between both T-cell based assays (QFN-G-IT and T-SPOT.TB) and TST in patients with psoriasis taking different immunosuppressant drug-regimens.

METHODS

We have prospectively studied 103 patients with moderate-to-severe psoriasis who required latent tuberculosis infection (LTBI) screening before starting systemic immunosuppressive treatment or during its sustained use.

RESULTS

Overall number of positive results was 16.5%, 17.5% and 8.7% using T-SPOT.TB, QFN-G-IT and TST, respectively. Differences in the percentage of positive results between TST with T-SPOT.TB and QFN-G-IT were significant (p = 0.005 and p = 0.008, respectively). A total of 24.3% of the subjects enrolled were positive for at least one of the three tests performed. Sixteen patients with negative TST (17%) were positive for one of the two IGRAs. We obtained seven indeterminate results by T-SPOT.TB and two by QFN-G-IT. Seven patients with negative TST presented indeterminate results by either of two IFN-γ assays. Positive TST, T-SPOT.TB and QFN-G-IT results were not affected by clinical therapeutic profile.

CONCLUSIONS

Our results reveal that in vitro assays are useful methods for LTBI diagnosis in patients with psoriasis, suggesting that they might be less influenced by immunosuppression than TST.