Do I need TB screening before starting biologics for RA?

Question

Hello doctor,

I am a 49-year-old woman with a 6-year history of rheumatoid arthritis, currently managed with Methotrexate and Hydroxychloroquine. My most recent labs show an ESR of 45 mm/hr and an elevated CRP. I continue to experience morning stiffness lasting nearly an hour, along with swelling in my finger joints, despite my current treatment.

Would it be appropriate to discuss the possibility of initiating a biologic therapy, such as Etanercept or Adalimumab, with my rheumatologist? Additionally, would I need to undergo TB screening before starting such therapy?

Thank you for your guidance.

Answer 1

Hi,

Welcome to icliniq.com.

Thank you for reaching out. I understand your concerns, and it is important to address them carefully. Based on your symptoms, it is quite possible that your current regimen of Methotrexate and Hydroxychloroquine may not be fully controlling your rheumatoid arthritis. Signs that indicate active disease despite treatment include:

Morning stiffness lasting more than 30 minutes.
Persistent joint swelling, particularly in the fingers.
Elevated ESR (45 mm/hr) and CRP.
Ongoing pain and fatigue.

These findings suggest moderate to high disease activity, which is a common reason to consider adjusting treatment.

Considering a biologic therapyYes, discussing biologic therapy with your rheumatologist is a good idea. Options often considered when Methotrexate alone is insufficient include:

Anti-TNF biologics:

Etanercept (Enbrel).
Adalimumab (Humira).
Infliximab (Remicade).

Other biologics:

Tocilizumab (IL-6 inhibitor).
Abatacept.
Rituximab (in specific cases).

Targeted oral therapies (JAK inhibitors):

Tofacitinib.
Baricitinib.
Upadacitinib.

These therapies are effective but require monitoring for potential risks, such as cardiovascular issues.

TB screening before starting biologics:TB screening is essential before starting any biologic or targeted synthetic therapy, especially anti-TNF agents, because these medications can reactivate latent tuberculosis. Screening may include:

Tuberculin skin test, Purified protein derivative (PPD) or Interferon-gamma release assay (IGRA) blood test (QuantiFERON-TB Gold).
Chest X-ray if indicated.

If latent TB is detected, treatment should be completed before initiating biologic therapy.

What Your Rheumatologist Will Consider:

Before switching to a biologic, your doctor will likely review:

Methotrexate dose and adherence.
Use of folic acid.
Liver function.
Recent infections.
TB history or exposure.
Vaccination status.

A helpful way to start the discussion could be:

My symptoms and inflammation markers remain high despite Methotrexate and Hydroxychloroquine.
Could we discuss the possibility of adding a biologic or JAK inhibitor?
Should I have TB screening done now?

This is a reasonable and appropriate conversation to have with your rheumatologist.

I hope this helps address your concern.

Please feel free to share your valuable feedback for improved patient care.

Thank you.