丹麦胃肠病学会提出了抗TNF制剂使用前的筛选和预防指南

摘要（丹麦）：丹麦胃肠病学会制定了有关起始抗TNF-α制剂治疗之前的筛选、预防及关键信息的收集工作三方面的国家级临床指南。抗TNF-α制剂被广泛用于治疗消化科、风湿科以及皮肤科疾病。基于此，丹麦胃肠病学会组成了一专家小组对起始抗TNF-α制剂治疗前的推荐证据进行了评估。筛选方面：应当筛选活动性结核和潜伏性结核。筛选乙型肝炎暴露/感染的风险，同时应评估其他病毒感染比如HIV、VZV。评估应该包括有无肿瘤的既往史（5年以内的肿瘤患者应用抗TNF-α制剂需格外小心）。体格检查应包括肺、心脏的听诊，淋巴结检查，辅助检查方面应包括胸部X线片，实验室检查方面包括干扰素γ释放试验，HBV、HIV检查，如不确定先前是否感染过VZV，还应查一下抗VZV抗体。预防方面：可疑的潜在性结核感染者应接受异烟肼治疗。推荐在HBsAg阳性的患者开始抗TNF-α制剂治疗时即起始抗病毒治疗。推荐起始抗TNF-α制剂治疗前接种肺炎球菌疫苗，推荐血清阴性的患者接种HBV疫苗。推荐接种季节性流感病毒疫苗。推荐依据丹麦国家卫生局的指南接种人乳头瘤病毒疫苗。在先前没有VZV感染的患者中推荐接种VZV疫苗。患者的信息：抗TNF-α制剂的应用使得感染和潜在结核复发的风险普遍增加。建议女性患者依据国家指南筛选宫颈癌，并明确各自HPV的免疫状态。生物制剂联合巯嘌呤类药物可增加淋巴瘤的罹患风险。建议带状疱疹感染的患者就医咨询。

附全文：Abstract These national clinical guidelines outlining the screening, prophylaxis and critical information required prior to initiating anti-TNF-alpha treatment have been approved by the Danish Society for Gastroenterology. Anti-TNF-alpha therapy is widely used in gastroenterology (for inflammatory bowel disease), rheumatology (for rheumatoid arthritis, psoriatic arthritis and spondyloarthropathies) and dermatology (for psoriasis). With this background, the Danish Society for Gastroenterology established a group of experts to assess evidence for actions recommended before treatment with anti-TNF-alpha agents. Screening should take place for both active tuberculosis and latent tuberculosis. Screening must evaluate the risk of hepatitis B exposure/infection and that of other viral infections such as human immunodeficiency virus (HIV) and varicella zoster virus (VZV). The assessment should include a history of previous malignancies (cases of malignant disease within 5 years of anti-TNF-alpha treatment should be carefully considered). The physical examination should include lung/heart auscultation and lymph node examination, and the paraclinical investigations should include chest X-rays and laboratory tests, including an interferon gamma release assay, a hepatitis B test, an HIV test and, when prior VZV infection is uncertain, a VZV antibody test. Prophylaxis: Isoniazid should be administered in cases of suspected latent TB infection. Antiviral treatment is recommended in HBsAg-positive patients at the start of anti-TNF-alpha treatment. Before anti-TNF-alpha therapy, vaccination with 23-valent pneumococcal vaccine is recommended, and HBV vaccination may be considered in seronegative patients. Annual vaccination against seasonal influenza is recommended. Human papilloma virus vaccination should be administered in accordance with the guidelines of the National Board of Health of Denmark. In patients without a prior VZV infection, VZV vaccination may be considered. Information for patients: Anti-TNF-alpha treatment results in a generally increased risk of infection and latent tuberculosis flare-up. Women are advised to comply with the national guidelines for screening for cervical cancer, and their HPV immunisation status should be clarified. An increased risk of lymphoma with biological therapy in combination with thiopurines should be mentioned. Patients are advised to seek medical advice in case of herpes zoster infection.

引自：Nordgaard-Lassen I, Dahlerup JF, Belard E, Gerstoft J, Kjeldsen J, Kragballe K, Ravn P, S?rensen IJ, Theede K, Tjellesen L; Danish Society for Gastroenterology. Guidelines for screening, prophylaxis and critical information prior to initiating anti-TNF-alpha treatment. Dan Med J. 2012 Jul;59(7):C4480.