Intest Res.  2018 Oct;16(4):588-598. 10.5217/ir.2018.00023.

High risk of tuberculosis during infliximab therapy despite tuberculosis screening in inflammatory bowel disease patients in India

• Agarwal A
• Kedia S
• Jain S
• Gupta V
• Bopanna S
• Yadav DP
• Goyal S
• Mouli VP
• Dhingra R
• Makharia G
• Ahuja V

• KMID: 2434161
• DOI: http://doi.org/10.5217/ir.2018.00023

Abstract

BACKGROUND/AIMS
The data on the risk of tuberculosis (TB) reactivation with infliximab (IFX) in patients with inflammatory bowel disease (IBD) from TB endemic countries, like India, is limited. The risk of TB reactivation on IFX and its predictors in patients with IBD was assessed.
METHODS
This retrospective review included consecutive patients with IBD who received IFX, and were on follow-up from January 2005 to November 2017. The data was recorded on age/disease duration, indications for IFX, screening for latent tuberculosis (LTB) before IFX, response to IFX, incidence and duration when TB developed after IFX, and type of TB (pulmonary [PTB]/extra-pulmonary [EPTB]/disseminated).
RESULTS
Of 69 patients (22 ulcerative colitis/47 Crohn's disease; mean age, 35.6±14.5 years; 50.7% males; median follow-up duration after IFX, 19 months [interquartile range, 5.5-48.7 months]), primary non-response at 8 weeks and secondary loss of response at 26 and 52 weeks were seen in 14.5%, 6% and 15% patients respectively. Prior to IFX, all patients were screened for LTB, 8 (11.6%) developed active TB (disseminated, 62.5%; EPTB, 25%; PTB, 12.5%) after a median of 19 weeks (interquartile range, 14.0-84.5 weeks) of IFX. Of these 8 patients' none had LTB, even when 7 of 8 were additionally screened with contrast-enhanced chest tomography. Though not statistically significant, more patients with Crohn's disease than ulcerative colitis (14.9% vs. 4.5%, P=0.21), and those with past history of TB (25% vs. 9.8%, P=0.21), developed TB. Age, gender, disease duration, or extraintestinal manifestations could not predict TB reactivation.
CONCLUSIONS
There is an extremely high rate of TB with IFX in Indian patients with IBD. Current screening techniques are ineffective and it is difficult to predict TB after IFX.

Keyword

Colitis, ulcerative; Crohn disease; Latent tuberculosis; Mantoux; Interferon-gamma release tests

MeSH Terms

Colitis, Ulcerative
Crohn Disease
Follow-Up Studies
Humans
Incidence
India*
Inflammatory Bowel Diseases*
Infliximab*
Interferon-gamma Release Tests
Latent Tuberculosis
Male
Mass Screening*
Retrospective Studies
Thorax
Tuberculosis*
Ulcer
Infliximab

Figure

• 

  Fig. 1. Flowchart demonstrating response to infliximab in patients with UC. TB, tuberculosis.

• 

  Fig. 2. Flowchart demonstrating response to infliximab in patients with CD.

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