(Re-)introduction of TNF antagonists and JAK inhibitors in patients with previous tuberculosis: a systematic review

Background Tuberculosis (TB) is a common complication associated with treatment with tumor necrosis factor (TNF) antagonists and Janus kinase (JAK) inhibitors. However, there is uncertainty about the risk of TB relapse in patients with TB and comorbidities requiring treatment with these agents. Objectives Partner Site Hamburg-Lübeck-Borstel-Riems. To assess the risk of TB relapse in patients (re-)started on TNF antagonists or JAK inhibitors. Methods Systematic review. Data sources PubMed and Cochrane Library databases until 11 December 2023. Study eligibility criteria Studies reporting on patients with current or previous TB who were (re-)started on TNF antagonists or JAK inhibitors. Results Of 5018 articles screened for eligibility, 67 publications reporting on 368 TB patients who (re-)initiated treatment with TNF antagonists for underlying diseases were included. The median age was 42.5 years (95%CI: 40.4 – 42.5) and the proportion of female patients was 36.6% (n=74) of patients whose sex was reported. A total of 14 patients (3.8%, 95% CI: 2.1 - 6.3%) developed TB relapse after a median of 8.5 months (IQR: 6.8 – 14.8 months) following (re-)initiation of anti-TNF treatment. Furthermore, among 251 articles screened for eligibility, 11 reports on TB patients who were (re-)started on JAK inhibitors for underlying diseases were identified. The median age was 62 years (IQR: 48.5 – 68.5 years) and 45.5% (n=5) were female. Only one patient (9.1%, 95% CI: 0.2 – 41.3%) had TB reactivation ten months after starting treatment with ruxolitinib. In addition, 94 patients who were treated with TNF antagonists and two patients were temporarily treated with JAK inhibitors for prevention or treatment of paradoxical reactions were analysed. None of the publications reported microbiological failure or worsening of TB-related symptoms. Conclusions (Re-)initiation of TNF antagonists and JAK inhibitors may be relatively safe in patients with current or previous TB and the need for further treatment of underlying diseases.