BTS recommendations for assessing risk and for managing mycobacterium tuberculosis infection and disease in patients due to start anti-TNF-alpha treatment

- In patients receiving anti-TNF-alpha treatment there is an increased risk of clinical tuberculosis (TB) developing. - Patients should have a clinical examination, their history of any prior TB treatment checked, a chest X-ray and if appropriate a tuberculin test. Any patient with an abnormal chest X-ray or previous history of TB or TB treatment should be referred for assessment by a specialist with an interest in TB. - Patients with an abnormal chest X-ray and/or symptoms raising a suspicion of TB should be thoroughly investigated to exclude active disease. - Any patient with active TB, either pulmonary or non-pulmonary, should receive standard chemotherapy. - Patients with active TB should receive a minimum of 2 months full chemotherapy directed by a specialist in TB, before starting anti-TNF-alpha treatment. - Patients with an abnormal chest X-ray consistent with past TB, or a history of prior extra-pulmonary TB but who have received previous adequate treatment, should be monitored regularly. - Active TB should be excluded by appropriate investigations in patients with an abnormal chest X-ray or a history of prior pulmonary or extra-pulmonary TB not previously adequately treated, should have active TB excluded. Chemoprophylaxis should be given before commencing anti-TNF-alpha treatment. - For patients with a normal chest X-ray who are not on immunosuppressive therapy a tuberculin test is helpful in management: an algorithm is supplied. - For those with a normal chest X-ray who are on immunosuppressive therapy a tuberculin test will not be helpful and need not be undertaken. An individual risk-assessment should be made (Tables 3-4); if the annual risk of TB is greater than the risk of drug-induced hepatitis, then chemoprophylaxis should be given. If the risk of hepatitis is the greater the patient should be monitored regularly with suggestive symptoms promptly investigated to permit early diagnosis of active disease. An algorithm is supplied. In general, Black-African patients aged over 15, and all South Asians born outside the UK, should be considered for chemoprophylaxis with isoniazid for 6 months. - Close co-operation between clinicians prescribing anti-TNF therapy and specialists in the management of TB is strongly recommended.