Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression—risks, screening, diagnosis and management

Summary Background One quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune‐based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence. Aim To review the screening, diagnostic practices and medical management of LTBI in patients with IBD. Methods Published literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD. Results Screening for LTBI should be performed proactively and includes assessment of risk factors, an interferon‐gamma releasing assay or tuberculin skin test and chest X‐ray. LTBI treatment in patients with IBD is scenario‐dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD. Conclusions Proactive screening for LTBI is essential in patients with IBD undergoing immune‐suppressing therapy and several therapeutic strategies are available. Reporting of real‐world experience is essential to refining current management recommendations. Tuberculosis infection is of paramount relevance to the IBD population given the frequent use of immunosuppressive medications. Diagnosing latent tuberculosis infection provides a window of opportunity for treatment. The risks of reactivation with immunosuppressive therapy must be weighed against the risk of side effects, inconvenience of treatment and costs. It is important to consider infectious diseases physician input for decision making.