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Latent tuberculosis before anti-TNF therapy — ESEGH MCQ

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ModerateGI PharmacologyLatent tuberculosis before anti-TNF therapyESEGH

A 38-year-old woman with Crohn's disease is due to start infliximab. She was born in India and received BCG vaccination in childhood. She has no cough, fever, night sweats or weight loss. Her chest radiograph is normal, but an interferon-gamma release assay is positive. Assessment by the tuberculosis service finds no evidence of active tuberculosis. What is the most appropriate management?

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Correct answer: A — Start latent tuberculosis treatment before commencing infliximab

The positive IGRA, epidemiological background and exclusion of active disease indicate latent tuberculosis. Anti-TNF therapy impairs granuloma maintenance and substantially increases the risk of tuberculosis reactivation. The infliximab SmPC therefore requires latent-TB treatment to be started before infliximab is initiated, with timing coordinated between the TB and IBD teams. Childhood BCG does not account for a positive IGRA, so repeating or ignoring the result is inappropriate. BCG revaccination neither treats latent infection nor provides a safe route to immediate anti-TNF therapy. Corticosteroids are not an alternative to tuberculosis treatment and can further increase infection risk. A normal chest radiograph does not make untreated latent infection safe during infliximab therapy.

Reference: Remicade (infliximab) Summary of Product Characteristics, section 4.4, Tuberculosis, updated 30 July 2025. https://www.medicines.org.uk/emc/product/3831/smpc