Copyright
©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
Active tuberculosis in inflammatory bowel disease patients under treatment from an endemic area in Latin America
Flora Maria Lorenzo Fortes, Ney Boa Sorte, Victor D Mariano, Laíla D Andrade, Fernanda A Oliveira, Monique CA Santos, Cláudia Ivanilda N dos Santos, Catharina A Passos, Mila P Pacheco, Valdiana C Surlo, Neogélia P de Almeida, Jaciane AM Fontes, Andréa M Pimentel, Raquel Rocha, Genoile Oliveira Santana
Flora Maria Lorenzo Fortes, Ney Boa Sorte, Mila P Pacheco, Genoile Oliveira Santana, Pharmaceutical Sciences Pos-graduation Program, State University of Bahia, Salvador, BA 40460-120, Brazil
Flora Maria Lorenzo Fortes, Valdiana C Surlo, Neogélia P de Almeida, Jaciane AM Fontes, Andréa M Pimentel, Outpatient Gastroenterology Unit, General Hospital Roberto Santos, Salvador, BA 40286-901, Brazil
Ney Boa Sorte, Victor D Mariano, Fernanda A Oliveira, Monique CA Santos, Cláudia Ivanilda N dos Santos, Catharina A Passos, Life Sciences Department, State University of Bahia, Salvador, BA 41150-000, Brazil
Laíla D Andrade, Department of Medicine, FTC University, Salvador, BA 41741-590, Brazil
Raquel Rocha, Department of Sciences of Nutrition, School of Nutrition, Federal University of Bahia, Salvador, BA 41701-035, Brazil
Author contributions: Fortes FML was contributed to study design, patient identification, data collection, statistical analysis, drafting of the manuscript; Boa Sorte N was contributed to statistical analysis; Mariano VD, Andrade LD, Oliveira FA, Santos MCA, dos Santos CIN, Passos CA, Surlo VC, de Almeida NP, Fontes JAM and Pimentel AM were contributed to patient identification, data collection; Rocha R and Pacheco MP were contributed to manuscript review, technical or material support; Santana GO was contributed to study design, manuscript revision, supervision of the study and full access to all of the data in the study, responsible for the integrity of the data.
Institutional review board statement: The Roberto Santos General Hospital Research Ethics Committee approved this research under the opinion number 1935.651/2017. The patients signed the Informed Consent Term before any procedure.
Informed consent statement: All study participants identities were anonymized and details that might disclose their identities were omitted. For this type of study formal consent is not required.
Conflict-of-interest statement: Genoile O Santana: Advisory board–Janssen; Speaker–Abbvie, Ferring, Janssen, Takeda and UCB Pharma; Research–Janssen, Lilly, Pfizer, Roche and Takeda. The other authors declare that they have no conflict of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author atraquelrocha2@yahoo.com.br. Participants gave informed consent for data sharing.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
http://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Raquel Rocha, DSc, MSc, Assistant Professor, Department of Sciences of Nutrition, School of Nutrition, Federal University of Bahia, Avenida Araújo Pinho, 32, Canela, Salvador, BA 41701-035, Brazil. raquelrocha2@yahoo.com.br
Received: July 21, 2020
Peer-review started: July 21, 2020
First decision: October 18, 2020
Revised: November 5, 2020
Accepted: November 14, 2020
Article in press: November 14, 2020
Published online: November 28, 2020
BACKGROUND
There has been an increase in cases of inflammatory bowel disease (IBD) in recent years. There is also greater access and availability of immunosuppressive and biological agents, which increase the risk of opportunistic infection despite improving the quality of life and promoting mucosal healing. Tuberculosis (TB) remains a public health problem, and it has a high incidence in several countries. Therefore, knowledge of the risk of developing TB in patients with IBD is important.
AIM
To evaluate the risk of active TB in patients with IBD under treatment from an endemic area in Latin America.
METHODS
A standard questionnaire included demographic variables, clinical aspects of IBD disease, history of active TB during treatment, active TB characteristics and evolution, initial screening and results and time from the start of anti-tumor necrosis factor alpha (TNFα) to TB development.
RESULTS
Azathioprine, anti-TNFα and the combination of these two drugs were associated with a higher risk of active TB incidence. The TNFα blockers increased the relative risk of developing active TB compared to other treatments. All four multivariable models showed that the use of TNFα blockers alone or in combination with azathioprine was an important risk factor for the incidence of active TB. After adjustment for sex, age, type of IBD and latent TB, anti-TNFα with azathioprine increased the relative risk to 17.8 times more than conventional treatment. Late TB, which was diagnosed 3 mo after the start of anti-TNFα, was the most frequent.
CONCLUSION
Treatment with anti-TNFα increased the risk of active TB in IBD patients from an endemic area in Latin America. This risk was increased when anti-TNFα was combined with azathioprine. The time from the beginning of the treatment to the active TB diagnosis suggests a new TB infection.
Core Tip: We evaluated the relative risk of developing active tuberculosis in patients receiving treatment for inflammatory bowel disease. A total of 301 patients with inflammatory bowel disease were evaluated, and an interview was conducted using a standard questionnaire and a review of the medical record. We identified the treatment during the diagnosis of active tuberculosis and the screening and past treatment for latent tuberculosis. Immunosuppressive therapy, specifically azathioprine, anti-tumor necrosis factor alpha (TNFα) and the combination of these two drugs, was associated with an increased risk of active tuberculosis. When adjusted for sex, age, type of inflammatory bowel disease (IBD) and latent tuberculosis, anti-TNFα with azathioprine consistently increased the relative risk to 17.8 times more than conventional treatment. This report is the first study in Latin America to assess the relative risk of developing active tuberculosis in patients with IBD undergoing treatment.
