Minimizing tuberculosis during anti-TNF-alpha treatment

 

時間：97年06月28日(六) 8:30~11:30

地點：台北榮民總醫院中正樓13樓

 

Time

Topics

Speaker

Moderator

08:30~8:40

Opening Remarks

蕭光明主任

8:40~9:30

Mechanisms for tuberculosis reactivation with anti-TNF-alpha treatment

Dr. Keith E. Gilmer

林孝義主任

9:30~10:20

Management of latent tuberculosis infection: Taiwanese guideline and international recommendation

江振源醫師

蘇維鈞醫師

10:20~10:40

Coffee Break

10:40~11:20

Tuberculosis screening and anti-TNF-alpha treatment: Current recommendations

陳得源主任

藍忠亮副院長

11:20~11:30

Closing Remark

彭瑞鵬總院長

 

 

 

 

 

 

Name:     KEITH E. GILMER MD

 

Education:

1989-1991       Henry Ford Hospital, Rheumatology Fellowship, Detroit, Michigan

1991(3mo)       University of Michigan, Pediatric Rheumatology, Ann Arbor, Michigan

1986-1989      Henry Ford Hospital, Internal Medicine Residency, Detroit, Michigan

1982-1986       University of Illinois College of Medicine - Rockford, Rockford, Illinois

1978-1982       Northwestern University, Evanston, Illinois

 

Work Experience:

Currently          Centocor, Inc., Tokyo, Japan, Director Medical Affairs

2003-2005       Centocor, Inc., Horsham, Pennsylvania, Associate Director, Medical Affairs

2003                VA Medical and Regional Office Center, Togus, Maine,

Rheumatologist - Locum Tenens

1996- 2003      Gilmer Rheumatology, Rockford, Illinois, Medical Director, Rheumatology

1993-1996       Gardner Wellness Center, St. Lawrence Hospital, Okemos, Michigan

                        Rheumatologist and Hospitalist

1991-1993       Oklahoma City Clinic, Oklahoma City, Division Head, Rheumatology

 

Licensure and Credentials:

2005        American Board Of Internal Medicine, Re-Certified – Rheumatology

2004                Spinal Metrology Certification, University of Toronto

2002                Advanced Cardiac Life Support                                               

2000               Clinical Densitometrist, International Society for Clinical Densitometry

1994                Diplomate, American Board of Internal Medicine - Rheumatology

1991                Fellow, American College of Rheumatology

1990                Diplomate, American Board of Internal Medicine   

1987                Diplomate, National Board of Medical Examiners

 

Professional Services:

2003                National Medical Association

2002                Stateline Rheumatology Society, Founding Member

1999                Performing Arts Medicine Association, Board of Directors

1998                Chicago Rheumatism Society

1996                American Medical Association

1996                Illinois State Medical Society

1996                Winnebago County Medical Society

1995                Ingham County Medical Society

1991                Michigan State Medical Society

1991                Michigan Rheumatism Society

 

 

 

江振源Chiang Chen-Yuan, MD, MPH

Director, Department of Lung Health, International Union Against Tuberculosis and Lung Disease (The Union), 68, Boulevard Saint-Michel, 75006 Paris France

EDUCATIONS AND TRAINING

September 1981 – June 1988 ---------------------------------------------------高雄醫學院醫學系

July 1991 – June 1995 -----------------------------------住院醫師 台大醫院、慢性病防治局

August 2001 – May 2002 ----------------------------------------加州大學柏克萊分校公共衛生碩士

PROFESSIONAL EXPERIENCE

December 1999 - April 2002 ---------------------------------------示範中心主任, 慢性病防治局

April 2002 – June 2003 ------------------------------------------胸腔科主任, 衛生署胸腔病院

July 2003 – Dec 2006----------- Consultant, International Union Against Tuberculosis And Lung Disease (The Union), Paris, France

Consultant of National TB programme review of Nepal, Arkhangelsk, Russia, India, South Africa, Sri Lanka, Sudan and of FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop Tuberculosis) project in several countries in Asia and Africa

January 2004 – present ------------------------行政院衛生署防癆委員會

January 2007 – Present----------------------Director, Department of Lung Health, The Union

December 2007 – Present -----------WHO global task force on TB impact Measurement

 

Selected Publications

Ø          Chiang C-Y, Enarson DA, Bai K-J, Suo J, Wu Y-C, Lin T-P, Luh K-T. Factors associated with clinicians’ decision to stop anti-tuberculosis treatment before completing a full course. Int J Tuberc Lung Dis 2008;12:441-446.

Ø          Chiang C-Y, Enarson DA, Fujiwara PI, Van Deun A, Lee J-J. Strategies of XDR-TB risk management for health workers and other care givers. Expert Rev Resp Med 2008;2:47-54.

Ø          Chiang C-Y, Luh K-T, Enarson DA, Yang S-L, Wu Y-C, Lin T-P. Accuracy of classification of tuberculosis case in Taiwan. Int J Tuberc Lung Dis. 2007;11:876-81. 

Ø          Chiang C-Y, Trebucq A, Billo N, et al. A survey on tuberculosis services in hospitals in seven large cities in Asia and North Africa. Int J Tuberc Lung Dis. 2007;11:739-46.

Ø          Chiang C-Y, Enarson DA, Yu M-C, Bai K-J, Ruay-Ming Huang, Chih-Jen Hsu, Jen Suo, Tao-Ping Lin. Outcome of pulmonary multidrug-resistant tuberculosis: a six year follow-up study. Eur Respir J 2006; 28: 980–985.

Ø          Chiang C-Y, Riley L. Exogenous reinfection in tuberculosis. Lancet Infect Dis 2005;10:629-36

 

 

Management of latent tuberculosis infection: Taiwanese guidelines and international recommendations

 

Chiang Chen-Yuan, MD, MPH

International Union Against Tuberculosis and Lung Disease

 

The development of tuberculosis involves several transitional steps, beginning with exposure to M. tuberculosis, followed by tuberculosis infection, and in some instances, progression to tuberculosis disease. Each step involves different sets of factors. The probability of becoming infected with tuberculosis is related to the risk of exposure, the duration of exposure as well as the intensity of exposure. Given being infected, the progression from latent tuberculosis infection to tuberculosis disease depends on the ability of human body in containing tuberculosis infection. There is a temporal association between tuberculosis infection and progression to tuberculosis disease. Persons who are recently infected with tubercle bacilli are more likely to develop disease in the fist year following infection and the risk of developing disease subsequently decreases but may remain measurable for a long time. So far HIV infection is the most powerful risk factor associated with the transition from latent tuberculosis infection to developing tuberculosis disease. Further, silicosis, underweight, diabetes mellitus, chronic renal failure, carcinoma of head or neck, immunosuppressive treatment, gastrectomy, jejunoileal bypass, cardiac and renal transplantation, as well as smoking are risk factors associated with developing tuberculosis disease. Management of latent tuberculosis infection aims at identifying persons who are likely to be infected and among those who are infected, persons who had a considerable risk of developing disease. Antituberculosis agents are efficacious in reducing the risk of developing tuberculosis disease. Recommended regimens include isoniazid for 6-9 months, rifampin for 4 months, isoniazid and rifampin for 3 months. Rifampin and pyrazimide for 2 months was a regimen used in the USA but had a high rate of adverse reaction with a substantial number of fatality reported, which supports a recommendation against use.             

 

 

Tuberculosis Screening and Anti-TNF-alpha Treatment: Current Recommendations

Der-Yuan Chen, Joung-Liang Lan

Division of Allergy, Immunology and Rheumatology, Taichung Verterans General Hospital, Taiwan, R.O.C.

Background: Anti-TNF therapy has been found to be associated with an increased tuberculosis (TB) risk. Guidelines have recommended that TB screening should be carried out before starting anti-TNF therapy and appropriate prophylaxis should be initiated if evidence of latent TB infection (LTBI) exists.

Methods: One hundred and thirty-two patients with active RA (110 females and 22 males, mean age 55.6 ± 12.7 years) were enrolled. Before starting anti-TNF-α therapy (71 etanercept and 61 adalimumab), TB screening consisting of a detailed history, chest radiographs, tuberculin skin tests (TSTs) and QuantiFERON Gold (QFT) assays were performed in all RA patients. TST was performed using the Mantoux method. Positive TST was defined as the induration diameter is ≧5 mm. QFT-G test was performed according to the manufacturer’s instructions (Cellestis, Ltd., Australia).

Results: Before starting anti-TNF-α therapy, 57 RA patients (43.2%) had TST-positive (≧5 mm) and 34 (25.8%) had TST-positive (≧10 mm), while 47% of general population aged 20-59 year-old had TST-positive (≧10 mm) in Taiwan. Consistent with a recent report showing that a booster phenomenon was observed in 29% of RA patients, the two-step TST could increase positive rate by 19.1% in our RA patients. Positive QFT results were observed in 34 (25.8%) patients with RA before starting anti-TNF therapy. Among 34 patients who had TST-positive (≧10 mm), 17 (50%) had negative QFT results, suggesting TST-positive results may be due to non-tuberculosis Mycobacterial (NTM) infection or BCG effect. Of patients who had TST-negative (<5 mm), 10 (13.3%) had positive QFT results, suggesting TST-negative may be false negative. A total of 38 patients who had TST-positive (≧10 mm) or TST-positive (5-9 mm) with QFT-positive results were diagnosed as LTBI and received INH prophylactic therapy one month before starting anti-TNF therapy. During a period of two years, 1 (1.6%) developed suspected TB after adalimumab therapy and 1 (1.4%) developed NTM after etanercept therapy.

Conclusions: Based on our results, Taiwan’s CDC guideline and previous reports, current recommendations of LTBI screening may be as following: (1) Detailed history, chest radiographs and two-step TST should be performed in RA patients before starting anti-TNF therapy; (2) QFT assay can be helpful to diagnosis LTBI in RA patients who have an intermediate TST result (5-9 mm); (3) Prophylactic therapy should be given one month before starting anti-TNF therapy if RA patients with TST-positive result ≧10mm, combining TST result 5-9mm with positive QFT result, chest radiograph showing evidence of past TB, and a recent contact with active TB patients; (4) Annual TSTs and possible QFT assays should be considered in the follow-ups for RA patients receiving anti-TNF therapy, and any TST/QFT converter should receive prophylactic therapy. However, there are still a lost of issues to be documented in the future.