This narrative review synthesizes current evidence on latent tuberculosis infection (LTBI) reactivation mechanisms and risk levels associated with nine major classes of immunosuppressive agents (biological and non-biological), and collates FDA and EMA prescribing guidance on TB screening across these drug classes.
Multiple immunosuppressant classes — including B- and T-cell depleting agents, interleukin antagonists, cytokine antagonists, integrin antagonists, immune checkpoint inhibitors, kinase inhibitors, proteasome inhibitors, calcineurin inhibitors, glucocorticoids, and BCL-2 inhibitors — carry meaningful risk of LTBI reactivation, underscoring the need for systematic TB screening and preventive therapy before initiation.
As a narrative review, it does not perform a meta-analysis or quantify comparative reactivation rates across drug classes; risk estimates depend on the quality and heterogeneity of the underlying primary literature. No original patient-level data are presented.
Before starting any major immunosuppressive agent, screen patients for LTBI using both tuberculin skin test and IGRA, and initiate preventive treatment per FDA/EMA guidance — especially for TNF antagonists, JAK inhibitors, and T/B-cell depleting therapies, which carry the highest reactivation concern. Maintain vigilance for TB reactivation throughout the treatment course, even in patients who screened negative at baseline.
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