Biologic and targeted synthetic DMARDs, TNF inhibitors in particular, can reactivate latent tuberculosis and hepatitis B. In high-tuberculosis-prevalence settings such as India, the pre-treatment screen is not optional.
Before starting, screen for latent tuberculosis with an interferon-gamma release assay or tuberculin skin test plus a chest radiograph, and for hepatitis B with HBsAg, anti-HBc and anti-HBs, along with hepatitis C serology. Treat latent tuberculosis before or alongside starting the biologic per local protocol, and give antiviral prophylaxis for anyone HBsAg-positive or anti-HBc-positive at risk of reactivation.
Two practical points: a negative IGRA does not exclude tuberculosis in someone with strong exposure or an abnormal chest film, so judge clinically; and isolated anti-HBc positivity still warrants monitoring or prophylaxis because occult hepatitis B can reactivate. Record the screen and its actions before the first dose.
- Screen for latent tuberculosis (IGRA or tuberculin skin test plus chest radiograph) before any biologic or targeted synthetic DMARD.
- Screen for hepatitis B (HBsAg, anti-HBc, anti-HBs) and hepatitis C before starting.
- Treat latent tuberculosis before or with the biologic, and give antiviral prophylaxis for HBsAg or anti-HBc positivity at risk.
- Judge tuberculosis clinically where exposure is strong, and monitor isolated anti-HBc positivity for occult hepatitis B.
Why it matters
These drugs can reactivate latent tuberculosis and hepatitis B, and the pre-treatment screen prevents avoidable, sometimes fatal, reactivation.
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