Restarting biologic agents in rheumatology patients who developed tuberculosis under TNFα-inhibitor treatment

Background: TNFα-inhibitor(TNF-αI) treatment increases tuberculosis(Tb) risk.Whenever Tb develops, guidelines recommend to stop TNF-αIs.However, this may result in flare of the underlying disease.There is limited data about the safety of re-administration of biologics. Objective: To determine the safety of re-administration of biologic agents in patients who developed Tb during TNF-αI-treatment. Methods: 21 of 1867 rheumatology patients(11 men, mean age 38.4±13.2 years;mean disease duration 10.6±7.8 years) developed Tb(8 pulmonary, 13 extrapulmonary) under TNF-αI(15 with infliximab,3 adalimumab,3 etanercept).The mean follow-up period was 38.1±28.5 months. Results: Among 21 Tb patients,1 had military-Tb and died during the first month of Tb-treatment.TNF-αI was restarted in 15/20 remaining patients(75%).In 3 patients TNF-αI was restarted while Tb-treatment was ongoing (etanercept in 1 Behcet9s patient at month 3,rituximab in 2 RA patients at month 4),and in 12 patients, median 3.5 months (IQR:0.6-22.2 months) after Tb-treatment was completed.Tb relapsed as pulmonary-Tb in one Behcet patient on 18th month of infliximab. Infliximab was stopped and Tb-retreatment started for 6 months.At the 3rd month of Tb-treatment,etanercept was started due to severe uveitis and switched to canakinumab due to inadequate response after 15 months.After 3rd dose of canakinumab,the patient developed TB-meningitis and received another 9 months of anti-Tb treatment and is currently stable on Interferon-alpha therapy for 16 months. Conclusion: Biologic agents including TNF-αI,can be restarted in patients who had previously developed Tb under anti-TNF treatment.Careful follow-up for TB relapse is required.