The risk of tuberculosis related to tumour necrosis factor antagonist therapies: a TBNET consensus statement

TLDR

TNF‑α antagonists are effective for chronic inflammatory diseases but raise the risk of reactivating latent infections, particularly tuberculosis. This consensus statement summarizes current evidence and expert opinion to provide evidence‑based recommendations for reducing TB risk in patients considered for TNF‑α antagonist therapy. Screening for latent TB with interferon‑γ release assays or tuberculin skin tests—both in adults and children—followed by preventive chemotherapy is recommended for all patients receiving TNF antagonists. TNF antagonist therapy increases TB risk up to 25‑fold, but targeted preventive chemotherapy for patients with latent infection markedly reduces progression to active disease.

Abstract

Anti-tumour necrosis factor (TNF) monoclonal antibodies or soluble TNF receptors have become an invaluable treatment against chronic inflammatory diseases, such as rheumatoid arthritis, inflammatory bowel disease and psoriasis. Individuals who are treated with TNF antagonists are at an increased risk of reactivating latent infections, especially tuberculosis (TB). Following TNF antagonist therapy, the relative risk for TB is increased up to 25 times, depending on the clinical setting and the TNF antagonist used. Interferon-γ release assays or, as an alternative in individuals without a history of bacille Calmette-Guérin vaccination, tuberculin skin testing is recommended to screen all adult candidates for TNF antagonist treatment for the presence of latent infection with Mycobacterium tuberculosis. Moreover, paediatric practice suggests concomitant use of both the tuberculin skin test and an interferon-γ release assay, as there are insufficient data in children to recommend one test over the other. Consequently, targeted preventive chemotherapy is highly recommended for all individuals with persistent M. tuberculosis-specific immune responses undergoing TNF antagonist therapy as it significantly reduces the risk of progression to TB. This TBNET consensus statement summarises current knowledge and expert opinions and provides evidence-based recommendations to reduce the TB risk among candidates for TNF antagonist therapy.