A 28-year-old man comes to the gastroenterology clinic for follow-up of severe, fistulizing Crohn's disease. Despite treatment with oral corticosteroids, he continues to have persistent abdominal pain and multiple draining perianal fistulas. The decision is made to initiate therapy with infliximab, a tumor necrosis factor-alpha (TNF-alpha) inhibitor. The patient has no history of cardiovascular, respiratory, or liver disease. Which of the following tests must be obtained prior to starting this medication? (Select all that apply)
- Interferon-gamma release assayAnswer
- Hepatitis B surface antigen and core antibodyAnswer
- CTransthoracic echocardiogram
- DAntinuclear antibody titer
- EThiopurine methyltransferase activity
Answer
The necessary tests prior to initiating a TNF-alpha inhibitor are an interferon-gamma release assay and hepatitis B serologies.
Tumor necrosis factor-alpha (TNF-alpha) inhibitors, such as infliximab, adalimumab, and etanercept, cause profound immunosuppression by disrupting macrophage function and granuloma integrity. This poses a significant risk for the reactivation of latent infections. Specifically, latent tuberculosis can disseminate rapidly, and chronic hepatitis B virus infection can result in fulminant hepatic failure. Therefore, current guidelines mandate universal baseline screening for tuberculosis (via an interferon-gamma release assay or tuberculin skin test) and hepatitis B (via surface antigen and core antibody) before initiating any TNF-alpha inhibitor.
Step-by-Step Solution
Key Concept
Patients initiating TNF-alpha inhibitors must undergo baseline screening for latent tuberculosis and hepatitis B due to the high risk of severe reactivation.