Approach to screening for tuberculosis (TB) infection (latent TB) prior to initiation of a biologic agent or JAK inhibitor

JAK: Janus kinase; TB: tuberculosis; IGRA: interferon-gamma release assay; TST: tuberculin skin test; TNF: tumor necrosis factor; IL: interleukin.

* Biologic agents include TNF inhibitors (infliximab, adalimumab, etanercept, certolizumab pegol, or golimumab) and non-TNF agents (abatacept, tocilizumab, rituximab, anifrolumab, ustekinumab, sarilumab, IL-17 blockers, and IL-23 blockers). Janus kinase (JAK) inhibitors include tofacitinib, baricitinib, upadacitinib, deucravacitinib, and others.

¶ Either IGRA or TST may be used; IGRA is preferable if available, particularly for patients who are unlikely to return to have the TST read and for patients with a history of Bacille Calmette-Guérin (BCG) vaccination administered after 12 months of age. Refer to UpToDate topic on the approach to diagnosis (screening) of tuberculosis infection (latent tuberculosis) in adults for discussion of test result interpretation.

Δ A chest radiograph is considered abnormal if it demonstrates parenchymal abnormalities, particularly opacification of the upper lobe or superior segment of the lower lobe. Isolated findings of granuloma/scarring do not warrant workup for TB disease.

◊ Refer to separate UpToDate content for discussion of approach to treatment of TB infection.

§ The optimal interval between initiation of treatment for TB infection and administration of the immunosuppressive agent is uncertain; data to guide the approach are lacking. Patients can start the immunosuppressive agent at any time after starting treatment for TB infection. If feasible, we prefer to administer the immunosuppressive agent once the patient has completed at least several weeks of antituberculous treatment to verify that the patient is tolerating the antituberculous treatment.