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Tuberculosis Screening and Reactivation Among a National Cohort of Patients with Inflammatory Bowel Disease Treated with Tumor Necrosis Factor Alpha Antagonists

Background: Tumor necrosis factor antagonists (anti-TNFs) are effective in treating inflammatory bowel disease (IBD) but may cause reactivation of tuberculosis (TB). TB screening rates and related outcomes are not well described among patients with IBD. This study aims to evaluate the prevalence and determinants of TB screening before anti-TNF initiation and related outcomes among patients with IBD. Methods: We identified patients with IBD with filled prescriptions for anti-TNFs using the National Veterans Affairs administrative data sets. Determinants of TB screening were identified by univariate and multivariate analyses. Patients with TB reactivation were identified by ICD9 codes or prescriptions for isoniazid, and confirmed by chart review. Results: A total of 3357 patients with IBD were identified with filled anti-TNF prescriptions. Approximately 72% to 86% of patients received TB screening. In multivariate analyses, patients in rural areas were less likely to be screened for TB compared with those in urban areas (odds ratio 0.72, 95% confidence ratio 0.54–0.95). Patients who received care at academically affiliated facilities were more likely to have received screening for TB (odds ratio 1.49, 95% confidence ratio 1.31–1.95). In 7210 patient-years of follow-up on anti-TNF, TB reactivation was confirmed in 2 patients, both of whom had a history and treatment of latent TB before anti-TNF initiation. Conclusions: TB screening before anti-TNF is estimated to be between 72% and 86%. Receipt of care at urban, academic-affiliated, high-volume IBD facilities is associated with higher rates of screening. Reactivation of TB in a highly screened cohort is estimated to be 2.8 per 10,000 patient-years.