The study: Jandali B, Lyons M, Charles J, et al. A prospective observational study of disease severity and mortality in Hispanic American patients with systemic sclerosis. Arthritis Care Res (Hoboken). 2024 Jun;76(6):768–776.
TB Screening Lapses in New DMARD Users
By Eric T. Roberts, PhD, MPH, Gabriela Schmajuk, MD, MSc, Jing Li, MPH, Matthew Murrill, MD, PhD, & Jinoos Yazdany, MD, MPH
Why was this study done? Many biologic or targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) increase the risk of reactivation of latent tuberculosis (TB) infection, putting patients at risk for adverse events, including death. With a growing number of drugs available in rheumatology, it is important to investigate whether TB screening practices have kept pace with recommendations to minimize preventable patient safety events.
What were the study methods? Our population was patients in the RISE registry and Medicare patients who were incident users of a biologic or targeted synthetic DMARD. TB screening was assessed in both groups one and three years before the medication start date. We calculated the proportion screened overall by medication class and practice. We tested for demographic differences in screening using logistic regression.
What were the key findings? Among 2,853 new biologic or targeted synthetic DMARD users, 65.6% of patients had TB screening within one year; within three years, 72.9% were screened. By drug type, rates of screening within one year were reduced for Janus kinase (JAK) inhibitors (46%) and interleukin (IL) 17 inhibitors (11.5%). A lower proportion of patients who were Hispanic and Asian (vs. white) were screened. Practice screening rates ranged from 20.0% to 92.9% of patients within one year.
What were the main conclusions? We report higher TB screening rates than previously published because we combined Medicare claims and electronic health record data. However, important safety gaps remain, namely, lower than expected screening among new users of a JAK or IL-17 inhibitor and among patients who were Asian and Hispanic. We cannot rule out that these patients were screened remotely (more than three years before drug initiation), but it may still be in the best interest of patients to update screening in those who have been off DMARDs for some time and are starting therapy, especially given the rising incidence of TB in some U.S. areas.
What are the implications for patients and clinicians? Our findings highlight important safety gaps and serve as a reminder of the importance of preventive screening before initiating therapy with DMARDs for all patients. Ideally, we will get to the place of zero preventable harm by building systems to ensure eligible patients are consistently screened across the country.
