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without authorization.
Infection with Mycobacterium tuberculosis can present with both tuberculosis and latent infection with Mycobacterium
LTBI refers to the presence of a long-term immune response to its antigen after infection, but no clinical tuberculosis, and no evidence
of clinical etiology or radiographic active tuberculosis.
A recent multicenter, cross-sectional study in China showed that the standardized prevalence of active tuberculosis in rheumatic disease patients was 882 per 100 000, significantly higher than the prevalence of 15-year-olds (459 per 100,000)
reported in the fifth national tuberculosis epidemiological sample survey in 2010 ≥ 15 years.
Other studies have shown that patients with
are found in patients
In summary, clinicians need to test
for LTBI in these eligible populations in patients with rheumatic disease, given immunocompromise, increased risk of LTBI, and significantly increased risk of developing active tuberculosis.
Recently, domestic experts in the field of tuberculosis and rheumatic diseases jointly wrote and released the "Expert Consensus on the Diagnosis and Treatment of Latent Infection with Mycobacterium tuberculosis in Patients with Rheumatic Diseases" (referred to as the consensus).
Based on the epidemiology, evidence-based medical evidence and clinical research data of rheumatic diseases combined with LTBI in China, 10 recommendations are put forward for clinical reference
.
10 consensus opinions
1.
For patients with rheumatic diseases who are to be treated with tumor necrosis factor inhibitors (TNFi), routine screening for LTBI (1A)
is recommended.
Non-TNFi biologics, such as
, have a low
risk of induced TB activity.
However, it is worth noting that the drug insert for Abatacept emphasizes that the presence of LTBI
should be screened before starting Abatacept therapy.
2.
Patients using targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs, such as
3.
For those who plan to use medium and large doses of glucocorticoids for a long time, especially those
if possible.
4.
Patients with rheumatic diseases who need long-term use of anti-rheumatic drugs (such as
5.
Patients with rheumatic diseases with a positive induration diameter of ≥ 10mm in tuberculin skin test, or patients who have received immunosuppressive treatment for > 1 month and an average diameter of induration ≥ 5mm in tuberculin
6.
For patients with rheumatic diseases, the accuracy of γ-interferon release test is better than that of tuberculin skin test, and it is recommended that patients with rheumatic diseases prioritize the use of γ-interferon release test to screen LTBI(1B).
7.
LTBI currently lacks a gold standard for diagnosis, and it is recommended to use a variety of methods for screening when available, such as γ-interferon release test combined with tuberculin skin test (2D).
When clinical screening for LTBI, a detailed history and relevant symptoms and signs should be collected before LTBI is measured
.
Symptom screening mainly includes:
.
A small number of patients present with acute manifestations such as moderate or high
.
The main purpose of asking patients about their symptoms is to rule out active tuberculosis and other diseases prior to preventive treatment, and to screen directly if these suspicious findings are not present (Figure 1).
Fig.
1 Screening and treatment process of latent infection with Mycobacterium tuberculosis in patients with rheumatic diseases
8.
Those who have completed standard anti-tuberculosis therapy within 5 years in the past can not be treated with prophylactic anti-tuberculosis therapy, and it is recommended that such patients prefer non-tumor necrosis factor inhibition (1B)
when using biological agents.
9.
If the condition allows, it is recommended that patients with rheumatic diseases with LTBI be treated with prophylactic anti-tuberculosis for at least 1 month before starting biologics; If the condition urgently requires immediate initiation of biologics, it is recommended to start both biologics and prophylactic antituberculous therapy (2D)
after adequate risk assessment.
10.
The 3HP regimen is i.
e.
isoniazid and rifapentine (isoniazid: 15 mg/kg per week; rifapentin: 750-900 mg per week; Table 1).
This program is a new recommended program in the world, and its advantages are short course of treatment, high treatment completion rate, and good efficacy, but the disadvantage is that the cost is high
.
Table 1 Detailed 3HP solutions
References: National Clinical Research Center for Infectious Diseases/Shenzhen Third People's Hospital, Peking University Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Chinese Antituberculosis Association, Editorial Board of Chinese Journal of Antituberculosis, Shenzhen Key Laboratory of Inflammatory and Immune Diseases.
Expert consensus on the diagnosis and treatment of latent infection with Mycobacterium tuberculosis in patients with rheumatic diseases[J].
Chinese Journal of Antituberculosis, 2022, 44(9): 869-879.
doi: 10.
19982/j.
issn.
1000-6621.
20220225
