Biological disease-modifying anti-rheumatic drugs (DMARDs) for the treatment of
Rheumatoid Arthritis, particularly TNF-α inhibitors, have been shown to improve patient
outcome by slowing or halting radiographic damage. However, similar to most immunemodulators,
there is an increased risk of infections co-incident with Tumour necrosis factor
(TNF)-α inhibitor use, particularly the risk of activated latent tuberculosis infection (LTBI).
Therefore, local and international guidelines recommend pre-screening for tuberculosis (TB)
prior to the initiation of TNF-α therapy in rheumatoid arthritis (RA) patients. Also of critical
importance in South Africa is the need for clinicians to be aware of environmental risk
factors such as TB being highly endemic.
Thus, a qualitative analysis was performed to investigate rheumatologists’ perceptions of TB co-incident with TNF-α inhibitors.
Method: Physicians (n=18) practising rheumatology in the private and public healthcare
sectors in Gauteng were interviewed to obtain their perceptions and attitudes related to TB
co-incident with TNF-α inhibitor use. Interviews were audio-recorded and the transcripts
analysed using thematic content analysis.
Results: The determinants of health equity: Affordability, accessibility and availability of
medicines (specifically TNF-α inhibitors) was reported to be different for the public care
versus the private care patient. The high cost of TNF-α inhibitors warranted funding predominantly by the private medical schemes. A higher occurrence of latent TB infection was reported by physicians practising in the
public or combined practice compared to the occurrence of LTBI in the private sector
(21.4%versus 1.5%).
The majority of study participants advocated pre-screening of TB, prior to the initiation of
TNF-α inhibitors, in RA. However, it was suggested that because of the high occurrence of
LTBI in the public sector, Isoniazid preventative therapy (IPT) should be compulsory,
irrespective of the patient’s TB status, for the duration of TNF-α therapy.
Most study participants supported local South African Rheumatism and Arthritis Association
(SARAA) guideline recommendation to re-screen for TB by chest x-ray (CXR), every 6
months. However, the value of re-screening using diagnostic tools, purified protein
derivative (PPD) skin test or interferon-gamma release assays (IGRAs) was queried due to
the possibility of false readings.
The occurrence of associated active TB in RA patients on TNF-α inhibitors was reported to be 0.07% in the private or combined practice versus 3.00% in the public sector. Forty
percent of TB cases were reported to be extra-pulmonary. Despite active vigilance, some
physicians reported that active TB month occurred months after the cessation of TNF-α
inhibitor therapy. [Similar findings were observed from the British Society for Rheumatology
Biologics Register (BSRBR)].
The majority of patients that developed TB co-incident with TNF-α inhibitors were treated
successfully with TB chemotherapy. Only 1 of 12 patients died of extra-pulmonary TB, following compassionate use of infliximab in public care.
Conclusion: Physicians practising rheumatology in Gauteng were of the opinion that there is
a TB risk associated with the use of TNF-α inhibitors for the management of rheumatoid
arthritis, as South Africa is a TB endemic country. Most acknowledged that these biological
DMARDs were efficacious in slowing or halting radiographic progression in rheumatoid
arthritis, but emphasised the need to take steps to prevent TB reactivation in the immuno -
compromised RA patients and to remain overtly vigilant for active TB.
In clinical practice, physicians mentioned that the monitoring and management of TB
associated with TNF-α inhibitors appears to follow the socio-economic status of the RA
patient and that distinct recommendations should be made for the public healthcare as well
as the private healthcare sectors.
Different opinions emanated from different physicians relating to the adequacy of local
SARAA guidelines for the prevention of TB associated with TNF-α inhibitors. Some physicians mentioned that local guidelines were sufficient, whilst other physicians mentioned that the
diagnostic tools were inadequate in the South African setting and that additional
precautions should be taken in the form of IPT for the full duration of TNF-α therapy for all
candidates, irrespective of TB status determined during pre-screening.
As the science of biological DMARDs evolves with the rapid development of new medicinal
therapies, physicians showed a preference to consider alternative non TNF-α biological
DMARDs that had a lower risk of associated TB, specifically in high-risk RA patients. Physicians’ overall perception of the management of RA with TNF-α inhibitor therapy was
that the risk-benefit assessment of these interventions, as well as patient preference and
economic considerations should be taken into account.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/14383 |
| Date | 28 March 2014 |
| Creators | Leong, Trudy D |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf, application/pdf |
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