SLE Medications Requiring TB Screening
TB screening is required before initiating glucocorticoids and immunosuppressive drugs in patients with SLE, according to local guidelines and CDC recommendations. 1
Medications Requiring TB Screening
High-Priority Medications
Glucocorticoids (corticosteroids): TB testing is recommended before starting glucocorticoids, especially at immunosuppressive doses, as SLE patients have a 2.5-13.8% TB frequency in endemic areas and 0-1.4% in low-incidence regions 1
Immunosuppressive drugs: TB screening is indicated before initiating any immunosuppressive therapy including: 1
- Cyclophosphamide
- Azathioprine
- Mycophenolate mofetil
- Methotrexate
Biologic Agents (If Used in SLE)
TNF-α inhibitors (adalimumab, infliximab, etanercept): These carry the highest TB reactivation risk with relative risks of 29.3 and 18.6 for adalimumab and infliximab respectively, requiring mandatory TB screening 2
Belimumab: While approved for SLE, screening recommendations should follow general immunosuppressive drug guidelines 3
Screening Approach
When to Screen
Before initiating treatment: TB testing should be performed according to local guidelines, especially before starting glucocorticoids and immunosuppressive drugs 1
Repeat testing: Only indicated for patients at increased ongoing risk of TB exposure 2
Testing Methods
Interferon gamma release assays (IGRAs): Have higher specificity than tuberculin skin test (TST) in BCG-vaccinated patients and better sensitivity in immunosuppressed patients 2
Combined approach: Using TST in combination with IGRA is justified to increase sensitivity in immunosuppressed SLE patients 2
Critical Clinical Considerations
Geographic Context
Endemic areas: Routine TB screening is more critical in regions with high TB prevalence (2.5-13.8% frequency in SLE patients) 1
Non-endemic areas: Routine TB testing in all SLE patients is not recommended, but screening before immunosuppressive therapy remains indicated 1
Treatment Implications
Prednisolone dose matters: Higher prednisolone doses during TB treatment are an independent mortality risk factor (HR 1.61 per 10 mg/day increase), suggesting doses should be kept below 25 mg/day during TB treatment when possible 4
Disease activity: SLE patients with TB have higher disease activity scores and more CNS involvement, complicating both diagnosis and management 4
Common Pitfalls
Underestimating glucocorticoid risk: Many clinicians focus on biologics but overlook that standard glucocorticoids and conventional immunosuppressants also require TB screening 1
Inadequate screening in immunosuppressed patients: TST alone may have reduced sensitivity in immunosuppressed SLE patients; consider combined testing approaches 2
Delayed screening: Testing should occur before initiating therapy, not after, as LTBI screening programs significantly reduce TB incidence 2