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P448 Safety of anti-TNF introduction following tuberculosis treatment in Inflammatory Bowel Disease patients in an endemic area

Azevedo, M.F.C.D.(1);Justus, F.F.(1);Lima, C.C.G.(1);Garcia, K.S.(1);Barros, L.L.(1);Oba, J.(1);Carlos, A.D.S.(1);Milani, L.R.(1);Sipahi, A.M.(1);Damião, A.O.M.C.(1);Queiroz, N.S.F.(1);

(1)University of São Paulo School of Medicine, Gastroenterology, São Paulo, Brazil

Background

Patients with inflammatory bowel diseases (IBD) have a greater risk of developing opportunistic infections, especially if they are under immunosuppressants and biological agents. Anti-tumor necrosis factor alpha (anti-TNF) has considerably increased the risk of tuberculosis (TB) in IBD patients. Brazil is considered an endemic area for TB and the safety of anti-TNF agents in IBD patients previous diagnosed with TB infection remains to be elucidated. The aim of this study was to evaluate the safety of anti-TNFs in patients with previous TB infection at a tertiary center in São Paulo, Brazil.

Methods

We retrospectively reviewed IBD patients with active TB followed in our center between January 2010 and December 2020. Data regarding disease phenotype, TB clinical presentation, IBD treatment at TB diagnosis and following TB treatment were collected from electronic medical records. TB diagnosis was based on symptoms, identification of the bacillus in body secretions, sample cultures, radiologic, endoscopic and histopathologic exams.

Results

Among 1040 IBD patients, we identified 37 patients with active TB (mean age at TB diagnosis 41.2 [25-69]; 59.4% male). Overall, 33 patients (89.2%) were under immunosuppressive medications. Of them, 27 (72.9%) were under anti-TNF drugs, 8 (29.6%) in monotherapy and 19 (70.3%) in combination with thiopurines or methotrexate. Pulmonary TB was the most common clinical presentation (40.5%) followed by disseminated TB (37.8%). Only 4 patients (10.8%) were not under immunosuppressant drugs and all of them were smokers. Sixteen (43.2%) patients received anti-TNF therapy after TB treatment, 4 of them had not been previously exposed to biologics. Median interval from TB diagnosis and anti-TNF initiation was 8 months (interquartile range [IQR] 4-24) and patients have been followed for a median of 34 months (IQR 7-108). Only one patient developed “de novo” tuberculosis, ten years after the first infection and after 48 months of treatment with infliximab and azathioprine.

Conclusion

Our findings suggest that treatment with anti-TNF following antituberculosis treatment is probably safe, even in endemic areas. TB occurred infrequently and after long-term follow-up, suggesting “de novo” infection rather than TB reactivation. This data emphasize the importance of periodic TB screening in IBD patients living in endemic areas.

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