From the Guidelines
TNF inhibitors should be used with caution in patients with sarcoidosis and extrapulmonary tuberculosis, and their use is contraindicated until the infection is adequately treated, as stated in the most recent guidelines 1. For sarcoidosis, TNF inhibitors like infliximab and adalimumab can be effective for refractory cases not responding to corticosteroids and conventional immunosuppressants. However, before initiating TNF inhibitor therapy, patients must undergo thorough tuberculosis screening including tuberculin skin test, interferon-gamma release assay, chest X-ray, and clinical evaluation. Some key points to consider when using TNF inhibitors in patients with sarcoidosis and extrapulmonary tuberculosis include:
- The risk of tuberculosis reactivation exists because TNF plays a crucial role in granuloma formation and maintenance, which contains mycobacterial infection, as highlighted in a study on the prevention, diagnosis, and management of infections in inflammatory bowel disease 1.
- Disrupting this process with TNF inhibitors can lead to tuberculosis dissemination, particularly with monoclonal antibodies like infliximab and adalimumab, which carry higher risk than etanercept, as noted in a study on the diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases 1.
- Patients with active TB should receive standard chemotherapy, and those with latent TB should receive prophylactic treatment before starting TNF inhibitor therapy, as recommended in the BTS guidelines for assessing risk and managing Mycobacterium tuberculosis infection and disease in patients due to start anti-TNF-alpha treatment 1.
- During treatment, patients require regular monitoring for tuberculosis reactivation or worsening, including clinical assessments every 3-6 months and annual tuberculosis screening, as suggested in the ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease 1. The most recent and highest quality study on this topic is the 2021 ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease 1, which provides comprehensive recommendations for the use of TNF inhibitors in patients with sarcoidosis and extrapulmonary tuberculosis.
From the Research
Sarcoidosis and Extrapulmonary Tuberculosis with TNF Inhibitors
- Sarcoidosis patients with chronic disease often require prolonged treatment, and TNF inhibitors can be useful in treating chronic sarcoidosis 2.
- The use of TNF inhibitors, such as infliximab, adalimumab, and etanercept, has been studied in sarcoidosis, with infliximab being the most extensively studied 2.
- Tuberculosis (TB) and sarcoidosis have clinical, immunologic, and radiologic similarities, and the differential diagnosis is often a challenge 3, 4.
- There is a hypothesis that posits TB and sarcoidosis as being along the spectrum of the same disease, which has important implications for treatment decisions 3, 4.
- Treatment with TNF-α inhibitors, such as infliximab, can lead to signs of decreased CD4+ T cell alveolitis and decreased mastocytosis in the lungs of responders with sarcoidosis 5.
- A meta-analysis found that anti-TNF-α agents are effective in treating refractory sarcoidosis, with a slightly higher efficacy seen in extrapulmonary sarcoidosis 6.
- The use of anti-TNF-α agents in patients with extrapulmonary tuberculosis is not well established, and further research is needed to determine their safety and efficacy in this population.
- The diagnosis of sarcoidosis or tuberculosis can be difficult, and a classification system has been proposed to distinguish between the two diseases, including Sarcoidosis (S), Sarcoid-Tuberculous (ST), Tuberculous Sarcoid (TS), and Tuberculosis (TB) 4.