FRI0626 Screening for tuberculosis before tnf inhibitor therapy remains suboptimal: a multi-specialty, real world, nationwide experience in the united states
Authors: K. Ladak, T. J. Pan, C. MacLean
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background:</h3> Tumor necrosis factor-a inhibitors (TNFi's) effectively treat various autoimmune conditions, but drastically increase the risk of tuberculosis (TB) reactivation. Multiple international guidelines recommend screening for TB prior to initiating TNFi therapy. In the United States, this has also been incorporated into the Medicare Merit-Based Incentive Payment Systems (MIPS) quality measures, which affect physician remuneration. <h3>Objectives:</h3> To determine the proportion of patients screened for TB prior to initiating TNFi therapy. <h3>Methods:</h3> We retrospectively analyzed patients in the Truven MarketScan Database from 2011–2015. This is the largest dataset of its kind and contains deidentified inpatient and outpatient health information on over 100 million patients. We included patients ≥18 years old in our cohort who were initiating TNFi therapy, based on at least 1 filled prescription. To ensure these were new TNFi starts, we excluded patients without a 6-month washout period (i.e. during which time they could not be receiving biologic DMARDs). Continuous enrollment in the database was required during the washout period and 3 months after TNFi initiation. Our primary outcome was whether patients were screened for TB during the 6-month washout period, either by interferon gamma release assays (IGRA) or tuberculin skin testing (TST). Sensitivity analysis was performed to extend the eligible screening period to 12 months pre-drug. Descriptive statistics were represented as means and medians for continuous variables and as frequencies and percentages for categorical variables. <h3>Results:</h3> We identified 78,088 patients starting a TNFi. The mean age was 44.8 years and the cohort was 61% female. Adalimumab and Etanercept were the most common TNFi's. Regarding indication for TNFi, 50.8% of patients had a rheumatologic diagnosis, 22.4% gastrointestinal, 17.6% dermatologic, and 0.8% ophthalmic. Most patients received care from a rheumatologist, while 16.4% were managed by primary care alone. 36,918 (47.3%) were not screened for TB in the 6-month washout. By extending the pre-drug washout to 12 months, the proportion of unscreened patients improved mildly to 40.7%. 48.5% were screened by IGRA, 27% by TST, and 24.5% unknown. Steroid use, DMARD use and urban residence were associated with increased TB screening rates. <h3>Conclusions:</h3> Screening for latent TB prior to initiating TNFi therapy was poor, such that only 52.7% received appropriate pre-drug screening. Our study population of over 78,000 patients starting a new TNFi represents nationwide, real world data across various specialties in the United States. As clinicians, these results suggest we need to improve compliance with guidelines and quality measures. <h3>References</h3> 1. Singh JA, et al. Arthritis Care Res (Hoboken)2012;64:625–639. 2. Askling J, et al. Arthritis Rheum. 2005;52(7):1986–92. 3. Dixon WG, et al. Ann Rheum Dis. 2010;69(3):522–8. <h3>Disclosure of Interest:</h3> None declared