National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents - 24/04/13

Doi : 10.1016/j.jaad.2008.03.023

Sean D. Doherty, MD ^a, Abby Van Voorhees, MD ^b, Mark G. Lebwohl, MD ^c, Neil J. Korman, MD, PhD ^d, Melodie S. Young, MSN, RN ^e, Sylvia Hsu, MD ^a,^⁎
^a Department of Dermatology, Baylor College of Medicine, Houston, Texas
^b Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
^c Department of Dermatology, Mount Sinai School of Medicine, New York, New York
^d Department of Dermatology and the Murdough Family Center for Psoriasis, Case Western Reserve University/University Hospital of Cleveland, Cleveland, Ohio
^e private practice, Dallas, Texas

Reprint requests: Sylvia Hsu, MD, Professor, Department of Dermatology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.

Abstract

Background

Chronic immunosuppression is a known risk factor for allowing latent tuberculosis (TB) infection to transform into active TB. Immunosuppressive/immunomodulatory therapies, while highly efficacious in the treatment of psoriasis and psoriatic arthritis, may be associated with an increased rate of active TB in patients receiving some of these therapies.

Objective

Our aim was to arrive at a consensus on screening for latent TB infection in psoriasis patient treated with systemic and biologic agents.

Methods

Reports in the literature were reviewed regarding immunosuppressive therapies and risk of TB.

Results

Screening patients for latent TB infection before commencement of treatment is of utmost importance when beginning treatment with the tumor necrosis factor–⍺ inhibitors, T-cell blockers, cyclosporine, or methotrexate. The currently recommended method for screening is the tuberculin skin test. It is preferable that positively screened patients be treated with a full course of latent TB infection prophylaxis before immunosuppressive/immunomodulatory therapy is initiated. However, in the opinion of many experts, patients may be started on the immunosuppressive/immunomodulatory therapy after 1 to 2 months, if their clinical condition requires, as long as they are strictly adhering to and tolerating their prophylactic regimen.

Limitations

There are few evidence-based studies on screening for latent TB infection in psoriasis patients treated with systemic and biologic agents.

Conclusions

The biologic TNF–⍺ inhibitors are very promising in the treatment of psoriasis. However, because TNF–⍺ is also an important cytokine in preventing TB infection and in keeping latent TB infection from becoming active disease, the use of TNF–⍺ inhibitors has been associated with an increased risk of developing active TB. A higher incidence of TB has also been reported with other immunosuppressive/immunomodulatory treatments for psoriasis. It is, therefore, of utmost importance to appropriately screen all patients for latent TB infection prior to initiating any immunologic therapy. Delaying immunologic therapy until latent TB infection prophylaxis is completed is preferable. However, if the patient is adhering to his prophylactic regimen and is appropriately tolerating the regimen, therapy may be started after 1 to 2 months if the clinical condition requires.

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Abbreviations used : CDC, FDA, MTX, TB, TNF

Plan

Treatment of latent TB infection

Selection of TNF-⍺ antagonist

Treatment alternatives

Consensus

Funding sources: None.

Disclosure: Dr Van Voorhees has been a consultant and speaker for Abbott, Amgen, Centocor, and Genentech. Dr. Lebwohl has been a consultant for Abbott, Amgen, Astellas, Centocor, Genentech, and Wyeth; he has also been a speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Dr Korman has been a consultant for Abbott, Astellas, Centocor, and Genentech; he has also been a speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Ms Young has been a consultant and speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Dr Hsu has been a consultant for Abbott, Amgen, Biogen Idec, Centocor, and Genentech; she has also been a clinical investigator for Amgen and Centocor. Dr Doherty has no conflicts of interest to declare.