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  #1  
Old 06-02-2012
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Question infliximab + PPD > 5mm.. what now?

A 35-year-old woman is evaluated in the office before the initiation of infliximab for rheumatoid arthritis. She was diagnosed with rheumatoid arthritis 5 years ago, and her disease is inadequately controlled on methotrexate and
naproxen. She has no other complaints or medical problems and has no risk factors for tuberculosis. She has never been
screened for tuberculosis. Her physical examination is unremarkable except for changes compatible with active rheumatoid arthritis involving her hands and feet. A chest radiograph is normal. Forty-eight hours after administering the tuberculin skin test, there is 7 mm of induration at the injection site.
Initiation of which of the following is the most appropriate next step in this patient's treatment?

(A) Infliximab
(B) Isoniazid
(C) Isoniazid and infliximab
(D) Isoniazid, rifampin, pyrazinamide, and ethambutol
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A - she dont need any TB Rx
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C-- INH and infliximab
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Quote:
Originally Posted by tyagee View Post
A 35-year-old woman is evaluated in the office before the initiation of infliximab for rheumatoid arthritis. She was diagnosed with rheumatoid arthritis 5 years ago, and her disease is inadequately controlled on methotrexate and
naproxen. She has no other complaints or medical problems and has no risk factors for tuberculosis. She has never been
screened for tuberculosis. Her physical examination is unremarkable except for changes compatible with active rheumatoid arthritis involving her hands and feet. A chest radiograph is normal. Forty-eight hours after administering the tuberculin skin test, there is 7 mm of induration at the injection site.
Initiation of which of the following is the most appropriate next step in this patient's treatment?

(A) Infliximab
(B) Isoniazid
(C) Isoniazid and infliximab
(D) Isoniazid, rifampin, pyrazinamide, and ethambutol
Since she "has no risk factors for tuberculosis" the PPD is not considered positive in this case and therefore she can be started on (A) Infliximab.

According to some (NEJM) there is a rationale of starting patients concurrently on ATT with Infliximab to prevent against active TB with a positive PPD.

Quote:
Patients at high risk of developing active
tuberculosis are considered to have latent
tuberculosis infection if the skin induration
measures 5 mm or greater. This group includes
people:
• Infected with human immunodeficiency
virus (HIV), regardless of CD4 count
• In recent contact with someone with
active tuberculosis
• With fibrosis on a chest radiograph that is
consistent with prior tuberculosis infection
Receiving immunosuppressive treatment
equivalent to prednisone 15 mg/day or
greater
.
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Quote:
Originally Posted by tyagee View Post
A 35-year-old woman is evaluated in the office before the initiation of infliximab for rheumatoid arthritis. She was diagnosed with rheumatoid arthritis 5 years ago, and her disease is inadequately controlled on methotrexate and
naproxen. She has no other complaints or medical problems and has no risk factors for tuberculosis. She has never been
screened for tuberculosis. Her physical examination is unremarkable except for changes compatible with active rheumatoid arthritis involving her hands and feet. A chest radiograph is normal. Forty-eight hours after administering the tuberculin skin test, there is 7 mm of induration at the injection site.
Initiation of which of the following is the most appropriate next step in this patient's treatment?

(A) Infliximab
(B) Isoniazid
(C) Isoniazid and infliximab
(D) Isoniazid, rifampin, pyrazinamide, and ethambutol
definitely A.....

low risk pt.-PPD>15mm is considered +
high risk pt.-PPD>10mm is considered +
immunocompromised pt. or HIV+ -PPD>15mm is considered +.......
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just read a similar question in UWORLD.

the explanation said that patients with any kind of immunocompromised status-- using drugs/hiv/prescription medication etc

shud be PROPHYLAXED with INH+pyridoxine for 9 months if ppd is +ve more than 5mm
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ans is INH for 9 months.

infliximab reactivates TB !
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Quote:
Originally Posted by tyagee View Post
ans is INH for 9 months.

infliximab reactivates TB !
Agreed that infliximab reactivates latent TB but according to the question stem the patient has "has no risk factors for tuberculosis" and therefore negative for PPD with an induration of 7 mm. According to the PPD guidelines patients with "no risk factors for tuberculosis" the positive PPD should be over 15 mm.
So, the only reason she is at high risk for TB is because of her being on Methotrexate which is being equivalent to being on over 15 mg of Prednisone.
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Old 06-03-2012
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Quote:
Originally Posted by Novobiocin View Post
Agreed that infliximab reactivates latent TB but according to the question stem the patient has "has no risk factors for tuberculosis" and therefore negative for PPD with an induration of 7 mm. According to the PPD guidelines patients with "no risk factors for tuberculosis" the positive PPD should be over 15 mm.
So, the only reason she is at high risk for TB is because of her being on Methotrexate which is being equivalent to being on over 15 mg of Prednisone.
methorexate for 5 years-- is considered immunocompromised.

for that matter any immunosupressive/modulator drug regimen for a prolonged duration wud be considered immunocompromised.

even for steroid usage if you look at MTB for CK or kaplan.. they just state use of long term steroids (no mention of any specific dosage)
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i dont know

but patient who needs infliximab , for that patient PPD > 5mm means positive PPD.

even if this woman has no methotrexate in question or steroids, even then PPD > 5mm means positive .
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Quote:
Originally Posted by tyagee View Post
i dont know

but patient who needs infliximab , for that patient PPD > 5mm means positive PPD.

even if this woman has no methotrexate in question or steroids, even then PPD > 5mm means positive .
Totally wrong.:sorry:

The induration of >5mm is considered positive only in patients who are immunosuppressed.
I think you are confusing with patients who are already on infliximab and develop induration of >5mm on PPD testing.
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please what is the answer?
thanks
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ans is A ... isoniazid.

expln?

here it is.

Quote:
The most appropriate next step in this patient's management is
to initiate isoniazid.

Screening for latent tuberculosis is indicated
in patients prior to solid organ transplant,
initiation of
chemotherapy or tumor necrosis factor α (TNF-α) inhibitors
, or in the presence of other major immunocompromising conditions.
Adverse effects of TNF-α inhibitors include the risk for serious infection.
Quote:
The Centers for
Disease Control and Prevention recommend treatment of latent
tuberculosis infection for all patients planning to take a TNF-α
inhibitor who have a PPD result of 5 mm or more of induration
or a positive interferon-γ release assay.


Therefore, the most
appropriate treatment for this patient is isoniazid for 9 months.
@ novobiocin,
i think cut off PPD prior to "starting" infliximab therapy is 5mm. that what i got from reading expln. thoughts ?
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  #14  
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Thats what i have understood so far from the discussion,

Quote:
The cut of point for normal people in whom you want to start anti-TNF agents is >10 mm.

Source:
http://www.blackwellpublishing.com/a...D=761&id=79768
But in the question above we have to take notice of the fact that patient had been on methotrexate for the last one year, so for him the cut off will be >5 mm.
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