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Revista Portuguesa de Pneumologia

versão impressa ISSN 0873-2159

Rev Port Pneumol v.14 n.2 Lisboa mar. 2008

 

Recomendações para o diagnóstico e tratamento das tuberculoses latente e activa nas doenças inflamatórias articulares candidatas a terapêutica com fármacos inibidores do factor de necrose tumoral alfa. Revisão de Março de 2008*

 

Recommendations for the diagnosis and treatment of latent and active tuberculosis in inflammatory joint diseases candidates for therapy with tumor necrosis factor alpha inhibitors – March 2008 update*

 

João Eurico Fonseca1

Helena Lucas2

Helena Canhão1

Raquel Duarte2

Maria José Santos1

Miguel Villar2

Augusto Faustino1

Elena Raymundo2

 

Resumo

A Sociedade Portuguesa de Reumatologia e a Sociedade Portuguesa de Pneumologia actualizaram as recomendações para o diagnóstico e a terapêutica das tuberculoses latente (TL) e activa (TD) em doentes com doenças inflamatórias articulares (DIA), candidatos a tratamento com antagonistas do factor de necrose tumoral alfa (TNFá).

Com o objectivo de reduzir o risco de reactivação da tuberculose (TB) ou nova infecção, recomenda-se o rastreio de TD e TL tão precocemente quanto possível, preferencialmente no momento do diagnóstico da DIA, e repetir a avaliação do doente antes de iníciar terapêutica anti-TNFá. O tratamento da TD e TL deve ser sempre supervisionado por um especialista em TB. Quando houver indicação para terapêutica de TB, esta deverá ser cumprida integralmente antes de se iniciar o anti -TNFá.

No caso da actividade da DIA o exigir, o anti –TNFá poderá ser iniciado após dois meses de terapêutica antibacilar, no caso de TD, ou após um mês, no caso de TL.

Todos os doentes devem realizar radiografia do tórax. Alterações compatíveis com complexo de Gohn devem ser tratadas como TL. Lesões residuais obrigam a excluir TB activa. Se se suspeitar de lesões em actividade, o diagnóstico de TD deve ser excluido e o tratamento adequado instituído.

A prova tuberculínica (PT), com 2 unidades de tuberculina RT23, deverá ser efectuada em todos os doentes. Se a induração for <5 mm, a prova deve ser repetida dentro de 1 a 2 semanas no antebraço oposto, e considerada negativa apenas se o segundo resultado for igualmente <5 mm. As PT positivas obrigam a tratamento de TL, excepto se o doente tiver sido previamente tratado de forma adequada. Se a PT é realizada apenas em fase de imunodepressão, mesmo que seja negativa, deve ser equacionado o tratamento de TL antes de iniciar terapêutica anti-TNFá, após ponderar a relação risco/benefício.

Palavras-chave: Guidelines, Sociedade Portuguesa de Reumatologia, Sociedade Portuguesa de Pneumologia, tuberculose, anti -TNFá.

 

Abstract

The Portuguese Society of Rheumatology and the Portuguese Society of Pulmonology have updated the guidelines for the diagnosis and treatment of latent tuberculosis infection (LTBI) and active tuberculosis (ATB) in patients with inflammatory joint diseases (IJD) that are candidates to therapy with tumour necrosis factor alpha (TNFá) antagonists. In order to reduce the risk of tuberculosis (TB) reactivation and the incidence of new infections, TB screening is recommended to be done as soon as possible, ideally at the moment of IJD diagnosis, and patient assessment repeated before starting anti -TNFá therapy. Treatment for ATB and LTBI must be done under the care of a TB specialist. When TB treatment is indicated, it should be completed prior to starting anti-TNFá therapy. If the IJD activity justifies the need for immediate treatment, anti-TNFá therapy can be started two months after antituberculous therapy has been initiated, in the case of ATB, and one month after in the case of LTBI. Chest X -ray is mandatory for all patients. If Gohn’s complex is present, the patient should be treated for LTBI; healed lesions require the exclusion of ATB. In cases of suspected active lesions, ATB should be excluded/confirmed and adequate therapy initiated.

Tuberculin skin test, with two units of RT23, should be performed in all patients. If the induration is <5 mm, the test should be repeated within 1 to 2 weeks, on the opposite forearm, and will be considered negative only if the result is again <5 mm. Positive TST implicates LTBI treatment, unless previous proper treatment was provided. If TST is performed in immunossuppressed IJD patients, LTBI treatment should be offered to the patient before starting anti-TNF -á therapy, even in the presence of a negative test, after risk / benefit assessment.

Key-words: Guidelines, Portuguese Society of Rheumatology, Portuguese Society of Pulmonology, Tuberculosis, Anti -TNFá drugs.

 

Texto completo disponível apenas em PDF.

Full text only available in PDF format.

 

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1 Rheumatoid Arthritis Study Group (Grupo de Estudos de Artrite Reumatóide -GEAR) of the Portuguese Society of Rheumatology (Sociedade Portuguesa de Reumatologia – SPR)

2 Tuberculosis Committee of the Portuguese Society of Pulmonology (Sociedade Portuguesa de Pneumologia – SPP)

* O presente artigo foi publicado simultaneamente in Acta Reumatol Port 2008;33:77-85

This article has been copublished in Acta Reumatol Port 2008; 33: 77-85

Correspondência/Correspondence:

Sociedade Portuguesa de Reumatologia

Rua D. Estefânia, 177-1.D, 1000-154 Lisbon

E-mail: info@spreumatologia.pt

 

Recebido para publicação/Received for publication: 08.02.21

Aceite para publicação/accepted for publication: 08.02.22