Recommendations for screening for latent tuberculosis infection in people with rheumatic diseases: Consensus...

Tuberculosis (TB) remains endemic in Asia, with latent TB infection (LTBI) being prevalent, especially among older adults. People with rheumatic diseases (PRD) who are treated with tumour necrosis factor-alpha inhibitors (TNF-I) are at increased risk of TB reactivation, prompting a strong recommendation for screening and treatment of LTBI prior to initiating TNF-I. However, the need for screening before starting non- TNF-I immunosuppressive agents remains unclear. This consensus statement from Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore, offers recommendations on LTBI screening before initiating non-TNF-I immunosuppressive agents, and the need for repeat LTBI testing in patients on TNF-I who initially tested negative.

Systematic literature reviews were performed to evaluate published guidelines and recommendations for LTBI screening before starting non-TNF-I immunosuppressive agents, and the need for repeat testing for LTBI during TNF-I use. Recommendations were formulated based on the evidence and expert opinion according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

The consensus comprises 3 overarching principles and 5 recommendations. We conditionally recommend that LTBI screening should be done before starting tocilizumab, Janus kinase inhibitors and moderate-to-high dose glucocorticoids. Conversely, routine screening need not be performed before starting cyclophosphamide. Annual testing for LTBI need not be performed routinely for patients on TNF-I if initial screening is negative.

These recommendations provide guidance for LTBI screening in PRD. All recommendations in this consensus are conditional, reflecting a lack of evidence or low-level evidence. These will be updated as new evidence emerges.