Low Tuberculosis Screening Rates Observed Among Patients Starting TNFis

Only about half of patients who started TNFi therapy were screened for tuberculosis prior to therapy initiation.
The following article is part of conference coverage from the European League Against Rheumatism (EULAR) Congress 2018 in Amsterdam, The Netherlands. Rheumatology Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in rheumatology. Check back for the latest news from EULAR 2018.

Only approximately half of patients in the United States who start tumor necrosis factor-alpha inhibitor (TNFi) therapy are screened for tuberculosis prior to therapy initiation, demonstrating a substantial need for greater adherence to screening guidelines among practicing physicians, according to a study presented at the European League Against Rheumatism (EULAR) Congress, held in Amsterdam, June 13 to 16, 2018.

“TNFis effectively treat various autoimmune conditions, but drastically increase the risk of tuberculosis reactivation,” the study investigators wrote. “Multiple international guidelines recommend screening for TB prior to initiating TNFi therapy. In the United States, this has also been incorporated into the Medicare Merit-Based Incentive Payment Systems quality measures, which affect physician remuneration.”

Patients with an autoimmune disorder for whom clinical data were recorded in the Truven MarketScan Database from 2011 to 2015 and who were scheduled to start therapy with a TNFi were included in the retrospective analysis (n=78,088). Only patients with a 6-month washout period were enrolled in the study. Screening for tuberculosis via interferon gamma release assays or tuberculin skin testing during a 6-month washout period comprised the primary outcome.

In the cohort, the most commonly prescribed TNFis were adalimumab and etanercept. Rheumatologic (50.8%), gastrointestinal (22.4%), dermatologic (17.6%), and ophthalmic (0.8%) indications represented reasons for TNFi therapy initiation. Only 16.4% of participants were treated by primary care providers, whereas the majority of patients received specialized care from a rheumatologist.

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Approximately half of all patients receiving TNFi were not screened for tuberculosis during the 6-month washout period (47.3%). Comparatively, only 40.7% of patients were not screened for tuberculosis prior to TNFi initiation when the investigators extended the predrug washout period to 12 months. Factors associated with tuberculosis screening included steroid and disease-modifying antirheumatic drug use as well as urban residence.

“Our study population of over 78,000 patients starting a new TNFi represents nationwide, real-world data across various specialties in the United States,” the researchers added. “As clinicians, these results suggest we need to improve compliance with guidelines and quality measures.”

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Ladak K, Pan TJ, MacLean C. Screening for tuberculosis before TNF inhibitor therapy remains suboptimal: a multi-specialty, real world, nationwide experience in the United States. Presented at: European League Against Rheumatism (EULAR) Congress 2018; June 13-16, 2018; Amsterdam, The Netherlands. Abstract FRI0626.