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Bedfellows: mycobacteria and rheumatoid arthritis in the era of biologic therapy

Nature Reviews Rheumatology volume 9, pages 524–531 (2013)Cite this article

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Abstract

In modern times a relationship between tuberculosis (TB) and rheumatoid arthritis (RA) has been firmly recognized, and is primarily attributable to the immunosuppressive therapies used to treat RA. Whereas TB can complicate the successful management of RA, nontuberculous mycobacteria have now perhaps become as important as (if not more so than) TB in the setting of RA, and can represent an even greater challenge to the rheumatologist wishing to use immunosuppressive therapies. This article reviews our most recent understanding of the epidemiological and clinical aspects of mycobacterial disease as it relates to RA, and the existing and emerging immunosuppressive therapies used to treat this disease.

Key Points

  • Patients with rheumatoid arthritis (RA) are at higher risk of disease from both tuberculosis (TB) and nontuberculous mycobacteria (NTM)

  • Some immunosuppressive therapies elevate the risk of mycobacterial disease, most clearly prednisone and TNF antagonists; other agents, such as tofacitinib, might also carry increased risk

  • In North America and other regions of low TB prevalence, NTM disease is more common than TB, particularly among patients with RA

  • Screening for latent TB infection prior to the start of therapy with biologic agents or tofacitinib is necessary, and can prevent overt TB disease

  • The safety of biologic therapy in patients with active NTM disease is unclear, and it should be avoided if possible in such patients

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Figure 1: Estimated global TB incidence rates, 2011.
Figure 2: Crude incidence rates of TB and NTM disease observed in the general population and in patients with rheumatoid arthritis in a large northern California health maintenance organization 2000–2008.28

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Acknowledgements

The authors thank Jennifer Ku for assistance with preparation and formatting of the manuscript.

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  1. Division of Infectious Diseases, Public Health and Preventive Medicine, Oregon Health & Science University, Terwilliger Boulevard, Portland, 97239, OR, USA

    Kevin L. Winthrop

  2. Department of Medicine, National Jewish Medical and Research Center, 1400 Jackson St, Denver, 80206-1997, CO, USA

    Michael Iseman

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K. L. Winthrop wrote the article. Both authors made substantial contributions to researching data for the article, discussions of content and review and/or editing of the article before submission.

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K. L. Winthrop declares that he has received research grant support from and acted as a consultant for Pfizer, and has acted as a consultant for Abbott, Cellestis, Oxford Immunotech, Roche and UCB. M. Iseman declares that he has acted as a consultant for Oxford Immunotech.

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Winthrop, K., Iseman, M. Bedfellows: mycobacteria and rheumatoid arthritis in the era of biologic therapy. Nat Rev Rheumatol 9, 524–531 (2013). https://doi.org/10.1038/nrrheum.2013.82

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