{"doi":"10.1002/acr.25533","title":"Reply","abstract":"We thank Wang et al for their letter regarding our study of tuberculosis (TB) screening before the administration of a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD)1 and for giving us the opportunity to clarify and expand on some important points. First, Wang et al suggest that treatment with interleukin-17 inhibitors (IL-17is) or JAK-inhibitors (JAKis) does not increase the risk of reactivation of latent tuberculosis infection (LTBI), and therefore screening before administration of these medication classes may be unnecessary. Indeed, a recent, large, multinational, retrospective observational study of patients with plaque psoriasis treated with an IL-17i or IL-23is documented only one case of LTBI reactivation in 405 patients treated for 32.87 ± 20.95 months.2 This is reassuring evidence of the type we called for in our discussion. However, it is important to note that contemporary practice is to screen and prophylactically treat all patients before drug initiation, so the true risk of LTBI reactivation is difficult to assess with current studies. Regarding JAKi, a recent review found less than 0.3% of 28,099 patients who were tofacitinib-exposed, and 4,310 patients who were baricitinib-exposed developed active TB with the authors concluding that the documented cases were likely community-acquired infections rather than LTBI reactivations.3 However, this review summarizes evidence from randomized controlled trials (RCTs), open label extensions, and national registries, and it is likely that all patients in RCTs and open label extension studies were screened before study entry, limiting inferences about LTBI reactivation. Further, there is insufficient evidence regarding TB risk associated with upadacitinib and filgotinib. Thus, we call for continued analyses of real-world evidence sources regarding the risk of LTBI reactivation across medication classes. We see the value of this kind of real-world evidence not to obviate screening but to enhance shared clinical decision-making. For example, some have adroitly pointed out that it may make clinical sense to preferentially choose an IL-17i when the patient presents with LTBI and a comorbidity that contraindicates TB chemoprophylaxis (eg, cirrhosis).2 However, this kind of decision-making requires LTBI screening. We agree that shared decision-making about treatment regimens and weighing individualized risks and benefits for patients are appropriate. Second, Wang et al advocate for targeted screening of high-risk patients because it may be a more cost-effective approach to identifying cases of LTBI in nonendemic locations like the United States. This raises two important questions: How would we best target screening efforts, and what is the cost of universal screening compared with missed cases? There are certainly important differences in the prevalence of LTBI by demographic and clinical characteristics.4 Risk stratification tools to predict developing active TB have been developed in Canada and Europe (TSTin4d and PERISKOPE-TB), though as inputs these models use a broad category of immunosuppression and the result of LTBI screening, which limits their utility for identifying whom to screen. We could assume that Wang et al are suggesting using a risk-based approach to screening for LTBI based on demographics and that such an approach would use nativity as it is biggest demographic predictor of TB in the United States. However, use of non-US place of birth alone would miss approximately one-quarter of TB diagnoses. From 2019 to 2023, there were 41,896 TB disease diagnoses in the United States. Of these, 11,106 were among US-born persons (27%).5 When you consider that there is indeed a cost to screen a patient but that this cost is nearly negligible compared with the cost of therapy with a biologic or the cost of treating a case of TB,6 and that TB reactivation is a preventable, potentially life threatening infection, we believe any small increas","journal":"Arthritis Care & Research","year":2025,"id":557456,"datarank":0.10397207708399181,"base_score":0.6931471805599453,"endowment":0.6931471805599453,"self_citation_contribution":0.10397207708399181,"citation_network_contribution":0.0,"self_endowment_contribution":0.10397207708399181,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":1,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9619,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2025-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1259354,"name":"Matthew Murrill","orcid":"0000-0001-7567-7727","position":1,"is_corresponding":false},{"id":58625,"name":"Gabriela Schmajuk","orcid":"0000-0003-2687-5043","position":2,"is_corresponding":false},{"id":24102,"name":"Jinoos Yazdany","orcid":"0000-0002-3508-4094","position":3,"is_corresponding":false},{"id":1259353,"name":"Eric T. Roberts","orcid":"0009-0005-8435-8994","position":0,"is_corresponding":true}],"reference_count":6,"raw_metadata":{"citation_network_status":"fetched"},"created_at":"2026-07-19T02:55:17.435961Z","pmid":"40167223","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}