Which latent TB infection (LTBI) screening tests should be performed before initiating treatment of rheumatoid arthritis (RA) with biologic agents?

Updated: Mar 05, 2021
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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Regardless of the risk factors for LTBI, the initial screening test for TB in patients with RA who are starting therapy with biologic agents should be the tuberculin skin test (TST) or interferon (IFN) gamma release assays (IGRAs). IGRAs are the preferred screening test in patients with a history of a bacillus Calmette-Guérin (BCG) vaccination; TST results in these patients have a high rate of false-positives.

ACR recommendations for further evaluation on the basis of the patient’s initial or repeat screening results are summarized in Table 2 below.

Table 2. 2015 ACR Recommendations for Further Evaluation After Initial/Repeat TB Screening Results (Open Table in a new window)

Result of Initial/Repeat TST or IGRA



  • Obtain chest x-ray

  • If the chest x-ray is suspicious for active TB, obtain sputum examination for active disease


In patients with RA but without risk factors or clinical suspicion for TB

  • No further workup is needed

In patients with RA and immunosuppression plus LTBI risk factors

  • LBTI is not excluded

  • Repeat the TST or IGRA 1-3 wk after an initial negative test result

Active/latent TB

  • Treat with appropriate antitubercular therapy

  • Refer to a specialist as necessary

  • Initiate or resume biologic agents after either 1 mo of treatment of LTBI with antitubercular regimen or completion of treatment for active TB

  • Screen annually in individuals with RA who (1) are continuing on biologic agents while living, traveling, or working in situations of likely TB exposure and (2) have a positive baseline for TST or IGRA; TST or IGRA may still be positive after successful TB therapy; monitor for clinical signs or symptoms of recurrent TB

ACR = American College of Rheumatology; IGRA = interferon gamma release assay; LBTI = latent tuberculosis infection; RA = rheumatoid arthritis; TB = tuberculosis; TST = tuberculin skin test.

Source:  Singh JA, Saag KG, et al2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care and Research http://dx.doi.org/10.1002/art.39480 (2015). [4]

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