What tuberculosis screening is recommended for medical students taking Rinvoq (upadacitinib)?

Tuberculosis Screening for Medical Students Taking Rinvoq (Upadacitinib)

Medical students taking Rinvoq (upadacitinib) should undergo comprehensive tuberculosis screening with both an interferon-gamma release assay (IGRA) and chest X-ray before starting therapy, with annual rescreening if TB risk factors are present.

Initial TB Screening Protocol

Required Screening Tests

• Interferon-gamma release assay (IGRA): Preferred first-line test (QuantiFERON-TB Gold or T-SPOT.TB) 1

  • Higher specificity (92-97%) compared to tuberculin skin test (TST) 2
  • Less affected by prior BCG vaccination 2
  • Preferred for healthcare workers and medical students who may have received BCG vaccination 1

• Chest X-ray: Required for all patients regardless of IGRA results 1

  • Look for any abnormalities suggestive of TB infection 1

Clinical Evaluation

• Assess for TB symptoms: cough >2 weeks, fever, night sweats, weight loss 1
• Evaluate TB risk factors:
  • Close contacts with TB patients
  • Foreign travel or origin from TB endemic areas
  • Prior TB history or treatment
  • Work in healthcare settings with potential TB exposure 1

Interpretation and Management

Positive IGRA Results

1. Rule out active TB:

   • Additional respiratory sampling (3 sputum specimens 8 hours apart) for AFB smear, culture, and nucleic acid amplification testing 1
   • Consider pulmonology consultation for further evaluation 1

2. If latent TB confirmed:

   • Complete at least 1 month of latent TB treatment before starting Rinvoq 1, 3
   • Treatment options include:
     • 6-month daily isoniazid
     • 9-month daily isoniazid
     • 3-month weekly rifapentine plus isoniazid
     • 3-4 month daily isoniazid plus rifampicin
     • 3-4 month daily rifampicin alone 1

Negative IGRA Results

• If no TB risk factors and normal chest X-ray: May proceed with Rinvoq therapy 1
• If immunosuppressed (already on steroids or other immunosuppressants): Consider dual testing with both IGRA and TST to increase sensitivity 2, 4

Ongoing Monitoring

Annual Rescreening

• Annual TB screening is recommended for patients with ongoing TB risk factors 1, 5
• Risk factors warranting annual screening include:
  • Close contact with TB patients
  • Travel to TB endemic areas
  • Work in healthcare settings with potential TB exposure 1

Special Considerations for Medical Students

• Medical students have occupational exposure risk due to clinical rotations in healthcare settings 1
• Higher priority for annual rescreening due to potential TB exposure 5
• Consider baseline two-step TST or IGRA before clinical rotations begin 2

Important Caveats

1. Immunosuppression Effect: Current immunosuppressive therapy (particularly azathioprine) can reduce IGRA sensitivity, potentially leading to false-negative results 4

   • Consider TB screening before starting any immunosuppressive therapy 4

2. Indeterminate Results: If IGRA results are indeterminate:

   • Repeat IGRA or perform TST 2
   • Consider chest radiography even with negative test results if clinical suspicion is high 1

3. TB Reactivation Risk: JAK inhibitors like Rinvoq increase TB reactivation risk, though possibly less than TNF-α inhibitors 6

   • The FDA label for Rinvoq specifically warns about TB risk and requires screening 3

4. Collaborative Care: Collaboration between rheumatologists, infectious disease specialists, and occupational health is recommended for medical students taking Rinvoq 1

By following this comprehensive screening protocol, medical students taking Rinvoq can minimize their risk of TB reactivation while maintaining effective disease control.