Efetividade da repetição do teste tuberculínico após exposição aos bloqueadores do TNF-alfa em pacientes com artropatias inflamatórias crônicas
Data
2021-08-26
Autores
Magalhães, Vanessa de Oliveira [UNIFESP]
Orientadores
Pinheiro, Marcelo de Medeiros [UNIFESP]
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução e Objetivos: Considerando o Brasil como país endêmico para tuberculose (Tb) e moderada prevalência de infecção tuberculosa latente (ITbL), este estudo teve o objetivo de avaliar a eficácia da repetição do teste tuberculínico (TT) em pacientes com artropatias inflamatórias crônicas (AIC) expostos aos inibidores de TNFα (iTNF).
Métodos: Estudo retrospectivo baseado banco de dados de prontuários eletrônicos que incluiu pacientes com artrite reumatoide (AR), espondilite anquilosante (EA) e artrite psoriásica (APs) e que tivessem realizado dois TT (0,1 mL PPD-RT-23, intradérmico), sendo o primeiro imediatamente antes de iniciar o iTNF e, o segundo, após, pelo menos 6 meses, de exposição. Todos os pacientes foram acompanhados rotineiramente em consultas regulares com o reumatologista. A incidência de Tb ao longo do tempo foi considerada como desfecho primário, que foi comparada com um grupo controle com as mesmas AIC e exposta aos iTNF, mas que não tinha feito o segundo TT. Múltiplos ajustes estatísticos para tipo de AIC, comorbidades, medicamentos concomitantes, tempo de exposição ao iTNF, indicação do segundo TT, idade e sexo foram feitos e p ≤ 0,05 foi considerado como significativo.
Resultados: Um total de 359 pacientes com AIC em uso de iTNF foram incluídos [AR, n=178; EA, n=135 e APs, n=46]. Não houve diferença estatisticamente significativa quanto aos dados epidemiológicos, demográficos ou clínicos entre os grupos. Após o uso de iTNF, houve incremento significativo da conversão de TT (15-27%) em todos os grupos, com incidência global de ITbL=10,55; IC95% 5,77-17,7, independentemente da AIC e iTNF. Durante o seguimento de 10 anos, ocorreram 27 casos de Tb (incidência=12,32; IC95% 8,12-17,93), principalmente em homens com EA, independentemente dos medicamentos modificadores sintéticos do curso de doença, glicocorticosteróides ou iTNF. Comparando os dois grupos, a única variável que se associou com a incidência de Tb foi a suspeita clínica (HR=11,31; IC95% 3,9-32,3), após múltiplos ajustes.
Conclusões: Embora a repetição do TT esteja associada com maior taxa de conversão após a exposição aos iTNF, ela não se associou como valor preditivo positivo para reduzir a incidência de Tb ao longo do tempo, exceto naqueles com evidência clínica de infecção ativa. Desse modo, a probabilidade pré-teste deve ser considerada durante o manejo clínico de pacientes com AIC antes de solicitar o TT e os nossos dados não suportam a repetição do TT indiscriminadamente.
Introduction/Aim: Considering Brazil as an endemic country for tuberculosis (TB) and moderate prevalence of latent tuberculosis infection (LTBI), this study aimed to evaluate the effectiveness of repeating the tuberculin skin test (TST) in patients with chronic inflammatory arthropathies (CIA) exposed to TNFα inhibitors (TNFi). Methods: Retrospective study based on electronic medical records, including rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA), that performed two TST (0.1 mL PPD-RT-23, intra-dermally), being the first immediately before starting TNFi and the second after exposition to them. All patients were routinely followed up in regular appointments from two large tertiary centers. The TB occurrence was considered as primary endpoint. Multiple statistical adjustments to concomitant medications, exposition time to TNFi, indication to second TST, age and sex. Appropriate statistical analyses were performed and p ≤ 0.05 was significant. Results: 359 CIA patients on TNFα inhibitors, at least 6 months before, [RA, n=178; AS, n=135, and PsA, n=46] were included. There was no significant statistically difference concerning epidemiological, demographic or clinical data among the groups. After using TNFi, there was significant increment of TST conversion (15-27%) in all groups, regardless CIA and TNFi. During the 10-Year follow-up, there were 27 cases of TB (incidence=12,32; IC95% 8,12-17,93), mostly in AS, males, regardless conventional DMARDs, glucocorticoids or TNFi. However, the only variable associated with TST repetition and new cases of TB (HR=11,31; IC95% 3,9-32,3), was clinical suspicious, after multiple statistical adjustments. Conclusions: Our results showed TST repetition is associated with higher significant conversion rate after long-term TNFi exposition. On the other hand, it had no positive predictive value for TB diagnosis over time, except in those with clinical evidence for active infection, suggesting the pretest probability should be considered during clinical management of CIA patients before requesting the TST. Therefore, our data do not support TST repetition indiscriminately
Introduction/Aim: Considering Brazil as an endemic country for tuberculosis (TB) and moderate prevalence of latent tuberculosis infection (LTBI), this study aimed to evaluate the effectiveness of repeating the tuberculin skin test (TST) in patients with chronic inflammatory arthropathies (CIA) exposed to TNFα inhibitors (TNFi). Methods: Retrospective study based on electronic medical records, including rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA), that performed two TST (0.1 mL PPD-RT-23, intra-dermally), being the first immediately before starting TNFi and the second after exposition to them. All patients were routinely followed up in regular appointments from two large tertiary centers. The TB occurrence was considered as primary endpoint. Multiple statistical adjustments to concomitant medications, exposition time to TNFi, indication to second TST, age and sex. Appropriate statistical analyses were performed and p ≤ 0.05 was significant. Results: 359 CIA patients on TNFα inhibitors, at least 6 months before, [RA, n=178; AS, n=135, and PsA, n=46] were included. There was no significant statistically difference concerning epidemiological, demographic or clinical data among the groups. After using TNFi, there was significant increment of TST conversion (15-27%) in all groups, regardless CIA and TNFi. During the 10-Year follow-up, there were 27 cases of TB (incidence=12,32; IC95% 8,12-17,93), mostly in AS, males, regardless conventional DMARDs, glucocorticoids or TNFi. However, the only variable associated with TST repetition and new cases of TB (HR=11,31; IC95% 3,9-32,3), was clinical suspicious, after multiple statistical adjustments. Conclusions: Our results showed TST repetition is associated with higher significant conversion rate after long-term TNFi exposition. On the other hand, it had no positive predictive value for TB diagnosis over time, except in those with clinical evidence for active infection, suggesting the pretest probability should be considered during clinical management of CIA patients before requesting the TST. Therefore, our data do not support TST repetition indiscriminately
Descrição
Citação
MAGALHÃES, V.O. Efetividade da repetição do teste tuberculínico após exposição aos bloqueadores do TNF-alfa em pacientes com artropatias inflamatórias crônicas. São Paulo, 2021. 58 f. Dissertação (Mestrado em Ciências da Saúde Aplicadas à Reumatologia) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2021.