P296 Isoniazid prophylaxis may not prevent tuberculosis reactivation during anti-TNF treatment
F. Akyuz1, R. Iliaz1, S. Evirgen1, S.Y. Onder2, K. Koksalan3, C. Karaca1, K. Demir1, F. Besisik1, S. Kaymakoglu*1
1Istanbul University, Department of Gastroenterology, Istanbul, Turkey, 2Istanbul University, Department of Pathology, Istanbul, Turkey, 3Istanbul University, Institute for Medical Experimental Research, Istanbul, Turkey
Treatment with tumour necrosis factor antagonists(anti-TNF) has been recognized as a risk factor for tuberculosis(TB) reactivation. Isoniazid(INH) prophylaxis is recommended according to baseline TB screening tests(tuberculin skin test, QuantiFERON®-TB Gold test) and chest X-Ray. However, the effectiveness of the chemoprophylaxis in the long term period is not clear, especially in the high prevalence countries for TB.
In this retrospective study, it was reviewed the medical records of 1263 patients with inflammatory bowel disease(IBD), and 1 rheumatoid arthritis and 1 hidradenitis suppurativa patients who attended for exudative ascites. Baseline TB screening tests including purified protein derivative(PPD) test and/or QuantiFERON®-TB Gold test were performed in all patients before starting anti-TNF therapy. PPD >5 mm and/or patients with positive QuantiFERON®-TB Gold test received INH prophylaxis for 9 months. We analyzed the data of patients diagnosed with TB reactivation during the anti-TNF treatment despite INH chemoprophylaxis.
Anti-TNF treatment rate was 13.9% (n=175) among IBD patients (137 patients [117 infliximab, 20 adalimumab] with Crohn's disease(CD), and 38 patients [34 infliximab, 4 adalimumab] with ulcerative colitis(UC). Six patients (4 males, mean age: 44.5 ± 18.6 years) on anti-TNF treatment (3 CD, 1 UC, 1 rheumatoid arthritis and 1 hidradenitis suppurativa) were enrolled in this study for developing TB reactivation despite INH prophylaxis. TB reactivation was occurred in 6.6% (n=4/60) of IBD patients who received INH prophylaxis beside anti-TNF treatment. Patients' PPD tests were positive in 4 and anergic in 2 patients. Anergic patients were positive for QuantiFERON®-TB Gold test. All these 6 patients received INH therapy(300 mg/day) for 9 months. Active TB was diagnosed at 33 ± 26 (range: 12-84) months of the anti-TNF treatment. Four of them received adalimumab and the others infliximab. Only one patient used also azathioprine during the anti-TNF therapy and that patient was diagnosed with disseminated TB. In 3 patients, we detected mycobacterium species as Mycobacterium bovis, M. tuberculosis and M. genavense, respectively. In 2 TB patients, we diagnosed TB according to compatible findings of peritoneal biopsies. In one patient, TB was diagnosed according to clinical and laboratory findings.
Isoniazid chemoprophylaxis may not prevent reactivation of TB in the long term period of anti-TNF treatment. It should carefully and periodically screen the patients during the anti-TNF therapy for TB reactivation.