A 60-year-old man with seropositive RA has been on adalimumab for 8 months. He presents with low-grade fever, night sweats, and weight loss. Chest X-ray shows upper lobe cavitary lesions. Sputum AFB smear is positive. What is the most appropriate management?

• A Continue adalimumab and start antitubercular therapy
• B Stop adalimumab and wait for TB culture sensitivity before treatment
• C Switch adalimumab to etanercept and start antitubercular therapy
• D Stop adalimumab immediately and start antitubercular therapy ✓

Explanation

Anti-TNF therapy (especially monoclonal antibodies like adalimumab and infliximab) significantly increases risk of reactivation tuberculosis. The drug must be stopped immediately when active TB is diagnosed, and standard antitubercular therapy should be initiated. Continuing anti-TNF therapy during active TB can lead to disseminated disease. Screening for latent TB is mandatory before starting anti-TNF agents.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.