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Crohn's Disease Forum » General IBD Discussion » Positive TB test, on Humira 7 years-


05-01-2017, 09:08 PM   #1
Hillcountrymom
 
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Positive TB test, on Humira 7 years-

Hi! I just joined this forum and hoping someone can tell me what to expect. I have been on Humira for 7 years and just had a TB gold blood test. My result came back positive. I recently had a chest CAT scan and everything was normal. I'm not coughing or anything like that. I assume my GI will give me antibiotics. If so, do I have to go off the Humira while on them? Have others been through this, if so what was your treatment? Thank you for your help!
05-02-2017, 10:20 AM   #2
Beach
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I'm unsure of what your doctors recommendation will be. I don't have personal experience. Best of luck.

If it might help your mention reminded me of a situation my grandma had. She always tested positive for TB. Yet grandma never had symptoms of TB infection and lived to the old age of 89.

Out of curiosity of grandma's situation I read about TB. In René and Jean Dubos book on tuberculosis it was mentioned that during the hight of TB active infections, nearly every in America and Europe would have tested positive for TB - according to the authors. Not everyone experienced symptoms though. It was only a percentage that experienced various TB illnesses. Why that happened though wasn't understood at that time.
05-02-2017, 10:25 AM   #3
my little penguin
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From what I read
Postive ppd with negative chest X-ray = latent tb
Not active tb

Active tb
They treat with three abx
Latent
They treat with one abx

Although terms such as 'chemoprophylaxis' and 'preventive chemotherapy' have been used, 'treatment of latent TB' is recommended by the American Thoracic Society. Investigation of latent TB is mandatory prior to the initiation of TNF antagonist therapy. Notwithstanding the fact that monoclonal antibodies seem to present a higher risk for reactivation of latent TB than soluble TNF receptors, screening and treatment of latent TB is warranted for all TNF antagonists regardless of their different molecular structure. This recommendation is supported by an observational study of the Spanish register BIOBADASER. The rate of TB was reduced by 80% after implementation of the official recommendations for isoniazid therapy for 9 months in patients with either positive TST (or two-step TST), past history of untreated TB or chest radiograph suggestive of past TB.[4] Recommendations for the general population by the American Thoracic Society and the British Thoracic Society in 2000 underscore the relevance of performing targeted TST in patients at risk such as those with recent TB exposure or those receiving prolonged immunosuppressive therapies.[83,84] Special attention was paid to children because youth implies recent infection and an increased likelihood of developing disease. More recommendations and evidence-based guidelines for patients undergoing treatment with TNF antagonists are available in several countries.[4,57,85–88] These national guidelines establish recommendations on screening methods and test cutoffs, and interpretation for diagnosis of latent TB. The best therapy for latent TB and the time delay before starting TNF antagonist therapy are also included in these guidelines. However, recommendations have disagreements; the TBNET consensus is the only international document that provides evidence-based advice for the assessment of latent TB in these patients. Experts recommend treating latent TB in all patients with positive IGRA tests or TST. However, IGRA can give false-negative results in approximately 20% of TB patients,[68,89] therefore different screening tools for diagnosis of latent TB must also be considered. Most guidelines recognize a history of significant past exposure or abnormal chest x-rays (suggestive of past TB) as indication for treatment of latent TB in the absence of an immune response to M. tuberculosis.[4,85,87,90] In patients treated adequately in the past, treatment of latent TB is not recommended despite persistent specific immune responses. On the other hand, guidelines emphasize that in patients with a negative TST or IGRA result, treatment is required if there has been past exposure or documented prior untreated TB. When IGRA and TST tests yield discordant results, the TBNET consensus recommends a consideration of history of prior BCG vaccination. If BCG vaccination was performed, IGRA test result should prevail over the TST result. If the patient has never been vaccinated with BCG, positive IGRA or TST result should be considered as such (Figure 2). Different delay periods between TNF antagonist therapy and initiation of latent TB treatment have been proposed. Recommendations range from starting both treatments concurrently to waiting until 1 month after finishing latent TB treatment. Therapy recommended for the treatment of latent TB includes 9–12 months of isoniazid in monotherapy,[5] or combining 3 months of isoniazid and rifampicin.[90] UK and Swiss guidelines propose isoniazid for 6 months or rifampicin for 4 months to minimize hepatotoxicity.[8

From
http://www.medscape.com/viewarticle/743498_6
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05-02-2017, 10:28 AM   #4
my little penguin
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Shorter regimens might avoid poor adherence to the treatment, and improve prevention of active diseases.[49] The case of active disease is different; there is no evidence that length of anti-TB treatment needs to be prolonged in patients who develop active TB while undergoing treatment with TNF antagonists. Recommendations on delay before recommencing TNF antagonist therapy differs between countries. French guidelines advise waiting at for at least 2 months after the completion of active TB treatment. No data is available regarding TNF antagonist treatment while the patient is receiving active anti-TB chemotherapy,[91] however Portuguese and English guidelines suggest commencing treatment after 2 months of TB treatment. The TBNET consensus recommends completing the active TB treatment before starting TNF antagonist. The effect of TNF antagonist therapy on response to treatment of TB is unknown, and paradoxical responses to treatment after discontinuing infliximab have been interpreted as a possible immune reconstitution reaction. Nevertheless, this observation does not support continuing TNF antagonist therapy in the presence of active TB.[92,93]

From
http://www.medscape.com/viewarticle/743498_6
05-02-2017, 10:35 AM   #5
my little penguin
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Another thread on this
05-02-2017, 10:42 AM   #6
my little penguin
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05-02-2017, 10:44 AM   #7
my little penguin
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1. What is LTBI?


Figure – Mycobacterium tuberculosis bacilli, present in patients with latent tuberculosis infection, are seen in this electron micrograph
Persons with LTBI are infected with Mycobacterium tuberculosis (Figure) but are not clinically ill and have no symptoms or evidence of active TB. They have M tuberculosis organisms in their bodies that are alive but cannot spread TB infection to others. In these persons, findings on chest x-ray films are normal and sputum test results are negative for M tuberculosis, but they need treatment to prevent TB disease. Thus, eradication of TB is a realistic aim with treatment of LTBI in developed countries and in countries in which the prevalence of TB is low.1

2. What is the meaning of “remote TB infection”?
Is it different from “latent TB infection”?
“Remote infection” is an ill-defined term used sporadically in the TB community. Most experts agree it would refer to a previous TB infection that has been contained by the person’s immune system. However, some may interpret it as a previous TB infection that still carries some risk of reactivation. Remote TB infection is different from LTBI. M tuberculosis bacilli definitely are present in persons with LTBI.

3. Why is LTBI detection important in patients with RA?
Patients with RA have a 4-fold increased risk of TB infection compared with the general population2; therefore, they should be screened for LTBI regularly.1 Many patients with RA are treated long-term with corticosteroids (eg, 15 mg/d of prednisone for more than 1 month3). Studies associate corticosteroid use with an increased risk of LTBI activation to TB.4,5

Anti–tumor necrosis factor α (anti–TNF-α) therapy is strongly associated with reactivation of TB in patients with RA.4-6 Therefore, LTBI should be screened for and, if present, managed in all patients with RA for whom treatment with anti–TNF-α agents is to be started.7-10 Most cases of TB in patients who are receiving immunosuppressive therapy have been attributed to reactivation of TB infection.6,11,12 Overall, active TB disease develops in about 5% to 10% of patients with LTBI at some time in their lives.13-16 In about half of persons in whom active TB develops, it does so within the first 2 years of infection.

From
http://www.rheumatologynetwork.com/a...-and-diagnosis
05-02-2017, 10:57 AM   #8
my little penguin
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http://centerfortuberculosis.mayo.ed...ov2013-web.pdf
05-06-2017, 11:05 AM   #9
Hillcountrymom
 
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Wow! Thank you so much for all the info! My chest Xray did come back clear. Now I have to see the infectious disease doc to see what his plan of treatment is. Do you happen to know if most people can continue their Humira? Or do they have to stop it just in case the TB decides to become active?

Thank you again for all your help!
05-06-2017, 04:54 PM   #10
firebob
 
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I had a few know exposure to TB from 98 to 02 when i was on a rescue squad. Only one of them we know about and had on a mask before hand.

I started getting +ppd test in 04 and the place i was working at told me get treated or i'm fired. chest xrays were all clean.

I took INH for 9 months. The drug is hard on your liver, i was told to not drink much, and they did a few rounds of blood work during the treatment.

There is a TB Gold blood test, but don't think it tells much unless you have active tb.

I wish i had more useful info...
05-06-2017, 10:41 PM   #11
zacofalltrades
 
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QuantiFERON-TB Gold is positive if there are TB antigens present in the blood. The test measures the amount of something called interferon-gamma; this is something that is released by white blood cells in response to contact with tuberculosis antigens (cellular surface proteins) if infected. Since you had a negative CT, it is likely that you have TB in the latent stages and you will probably be directed to take INH for 6-9 months since you have a degree of immunosuppression from the Humira. TB can also be present in the bowel but the incidence of this is much less likely than a pulmonary manifestation.
05-18-2017, 07:47 AM   #12
Hillcountrymom
 
Join Date: May 2017
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Thank you all for your replies. I have another question. Not sure how often this comes up.

I met with the ID doctor and he did prescribe 9 months of INH, but to continue the Humira as well. I asked him to repeat the blood test just in case there was a mix up and that I didn't want to take 9 months of antibiotics if not needed. He did order another test and I just saw that my result was NEGATIVE! What? I started the INH four days ago thinking it would likely be positive.

I did have the second blood test a a different lab than the first.

Now I am just confused. I have a call in to the ID doctor. Have you ever heard of this before? Any advise is appreciated.
Thank you!
05-18-2017, 08:37 AM   #13
my little penguin
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CDC is clear
One blood test or skin test does not negate another
So if you had a postive ppd
And negative blood test then your still postive
If you have a postive blood test and later negative on a different type of blood test
Your still positive


Inh is used to prevent latent tb from becoming active tb
Humira puts folks at very high risk of active tb

The inh drug diesnt affect the gut like a normal abx

The risks are high for latent tb to active tb
If it's not treated and you continue humira


Hope your Id doc can help
05-18-2017, 11:41 AM   #14
Hillcountrymom
 
Join Date: May 2017
Location: Texas
Thank you!

I spoke to my ID doc. He said I could stop the INH and repeat the blood test in a month or continue it and repeat in a month. So no clear answer.

He said it is more likely to be false negative than false positive because of the importance of how the blood is handled after it is drawn. It has to be tested very soon. If it sits around on a desk for a while it will not give a true result.

I have no idea how the second lab handles their blood, but it was done at a military base hospital, so the doc said they are very good. The first was done at a Quest.


I think I am going to repeat the test in a month, but continue the INH and Humira. The thought of active TB on Humira really scares me. The thought of all this liver damage scares me as well. Ugh!

Is that what you would do?
05-18-2017, 12:09 PM   #15
my little penguin
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If your under 35 ( no need to say)
Then the risk of liver damage is extremely low
Over 35 then liver damage is a risk to be considered with inh

They monitor closely just like 6-mp and mtx
So the risk is there always
05-18-2017, 12:13 PM   #16
Hillcountrymom
 
Join Date: May 2017
Location: Texas
Yes, I have to have a blood test two weeks into the INH and then every month.

I am 42:-) So it sounds like a possibility. Ugh!

Sure appreciate all of your help/feedback/knowledge.
05-18-2017, 12:53 PM   #17
my little penguin
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The other thing if
You had negative tests in the past until recently
Then odds are you are newly exposed to tb
Tb that "new" has a higher chance of becoming active within two years
Of exposure

They hold off on treating the general public who is older since the risk is 5%
How ever humira changed those numbers
I would ask id what the risk numbers are for your age and humira
Turning to active tb with a fresh postive
05-19-2017, 12:32 AM   #18
tots
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My mom used to work as an admitting clerk in the ER, she was exposed to TB so she now
tests positive. So for her they would do a chest X-ray to confirm there never was a TB infection.

She never received treatment.


Lauren
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