Table 4.

Recommendations for the Screening and Management of TB in IBD Patients Treated with Anti-TNF Agents

	ECCO 2014 Guidelines66	BTS 2005 Guidelines67	Taiwan 2017 Guidelines68,69	AOCC and APAGE Consensus 2017, 201870,71
Screening recommendations	Screening to always be performed prior to anti-TNF therapy.	All patients should undergo clinical examination, a chest radiograph and, if appropriate, a TST.	Recommend routine screening for LTBI with chest X-ray (and if available, IGRA) or TST before initiating biologic treatment.	Recommend routine screening for latent or active TB prior to commencing anti-TNF treatment.
	IGRA is likely to complement the TST; should be preferred in BCG-immunized patients.	If abnormal chest radiograph or previous history of TB/TB treatment, then refer for assessment by a specialist with an interest in TB; investigate thoroughly to exclude active disease.	During biologic therapy, patients should be monitored for signs and symptoms of active TB with chest X-ray and IGRA performed at least annually.	Latent TB to be diagnosed based on prior history of TB treatment and contact with patients with TB, chest radiography, TST, and/or IGRAs.
	Diagnose LTBI using a combination of patient history, chest X-ray, tuberculin skin test and IGRA.			IGRAs preferred over TST in BCG-vaccinated individuals.
If LTBI	Treat with a complete therapeutic regimen for LTBI.	For patients with an abnormal chest radiograph consistent with past TB, or a history of prior extrapulmonary TB:	Prophylactic treatment for prevention of TB reactivation should be started at least 4 weeks before using biologics.	Treat with a therapeutic regimen for LTBI before the initiation of anti-TNF therapy.
	Delay anti-TNF therapy for at least 3 weeks after starting chemotherapy, except in cases of greater clinical urgency and with specialist advice.	-If received previous adequate treatment, then monitor regularly.		Chemotherapy not necessary if history of proper treatment of TB and no suspicion of newly acquired infection.
		-If not previously adequately treated, then exclude active TB by appropriate investigations. In these patients, the risk-benefit analysis strongly favors chemoprophylaxis, which should ideally be completed before starting anti-TNF treatment.		Delay anti-TNF therapy for at least 3 weeks after commencing LTBI treatment, except in urgent cases.
If active TB	Delay anti-TNF therapy for at least 3 weeks after starting chemotherapy, except in cases of greater clinical urgency and with specialist advice.	Patients with active TB should receive a minimum of 2 months of full standard chemotherapy before starting anti-TNF-α treatment.	Not specified.	If active TB diagnosed during anti-TNF therapy, withhold anti-TNF therapy, and commence standard duration anti-TB therapy.
	If active TB diagnosed after initiation of anti-TNF therapy, then start anti-TB-therapy and stop anti-TNF therapy; anti-TNF therapy may be resumed after 2 months if needed.	If active TB develops while on anti-TNF-α treatment, patients should receive full anti-TB chemotherapy. The anti-TNF-α treatment can be continued if clinically indicated to prevent flare up or major clinical deterioration.		In general, delay resumption of anti-TNF therapy until completion of anti-TB therapy; however, anti-TNF therapy may be restarted after 2 months of anti-TB therapy if patients demonstrate a favorable response to anti-TB therapy and require the early resumption of anti-TNF therapy.

TB, tuberculosis; IBD, inflammatory bowel disease; TNF, tumor necrosis factor; ECCO, European Crohn's and Colitis Organisation; BTS, British Thoracic Society; AOCC, Asian Organization for Crohn’s and Colitis; APAGE, Asia Pacific Association of Gastroenterology; IGRA, interferon-gamma release assays; TST, tuberculin skin test; BCG, Bacillus Calmette–Guérin vaccine; LTBI, latent tuberculosis infection.