Recommendations for screening for latent tuberculosis infection in people with rheumatic diseases: Consensus statement from the Singapore Chapter of Rheumatologists

Introduction Tuberculosis (TB) remains endemic in Asia, with latent TB infection (LTBI) being prevalent, especially among older adults. People with rheumatic diseases (PRD) who are treated with tumour necrosis factor-alpha inhibitors (TNF-I) are at increased risk of TB reactivation, prompting a strong recommendation for screening and treatment of LTBI prior to initiating TNF-I. However, the need for screening before starting non- TNF-I immunosuppressive agents remains unclear. This consensus statement from Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore, offers recommendations on LTBI screening before initiating non-TNF-I immunosuppressive agents, and the need for repeat LTBI testing in patients on TNF-I who initially tested negative. Method Systematic literature reviews were performed to evaluate published guidelines and recommendations for LTBI screening before starting non-TNF-I immunosuppressive agents, and the need for repeat testing for LTBI during TNF-I use. Recommendations were formulated based on the evidence and expert opinion according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results The consensus comprises 3 overarching principles and 5 recommendations. We conditionally recommend that LTBI screening should be done before starting tocilizumab, Janus kinase inhibitors and moderate-to-high dose glucocorticoids. Conversely, routine screening need not be performed before starting cyclophosphamide. Annual testing for LTBI need not be performed routinely for patients on TNF-I if initial screening is negative. Conclusion These recommendations provide guidance for LTBI screening in PRD. All recommendations in this consensus are conditional, reflecting a lack of evidence or low-level evidence. These will be updated as new evidence emerges.