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Biologics may provide excellent relief from psoriasis, but that relief comes with the potential for serious side effects, mainly associated with an altered immune system. As a result, Kevin Cooper, M.D., emphasizes the importance of making sure patients are physically and mentally prepared for undergoing biologic therapies.
If patients understand the risk/benefit ratio of available treatments for psoriasis and comorbidities and want to proceed, clinicians can perform a number of tests prior to prescribing biologics, according to Dr. Cooper, professor and chairman, department of dermatology, Case Western Reserve University and University Hospital Case Medical Center, Cleveland.
Biologics are a relatively new approach for treating psoriasis and cutaneous lymphomas. Most of the drugs have received Food and Drug Administration approval in the past decade. Because they are active proteins subject to proteolytic digestion in the gastrointestinal tract, biologics must be injected.
Before prescribing biologics, Dr. Cooper says he recommends obtaining a medical history and exam for mycobacterial, fungal, bacterial, viral or opportunistic pulmonary infections, and hepatitis B or C. This class of drugs can exacerbate or instigate these conditions.
A tuberculosis skin test prior to starting therapy also is essential. Dr. Cooper also recommends a baseline CBC with differential, hepatitis screen and liver function tests (LFTs).
"If the patient is already immunized against hepatitis B, I may not do the chemistry hepatitis B panel, but otherwise I do want to make sure there is no chance of active hepatitis," he says. "You want to take a careful history for pulmonary disease, any history of tuberculosis or fungal infections of the lungs."
With Stelara (ustekinumab, Janssen Biotech), an antibody that neutralizes interleukin-12 (IL-12) and interleukin-23 (IL-23), "There is concern for infection susceptibility, including GI infections, and nervous system abnormalities. Special attention to headaches and visual changes should be provided," Dr. Cooper says. "Again, I do a careful history for pre-existing infections and autoimmune sensitivities, a baseline PPD test, a CBC with differential, and LFTs."
Flow sheets prompt the physician to repeat blood tests quarterly, and the PPD annually.
"With Stelara, a history and a limited physical exam should be done every time an injection is given to make sure there are no adverse effects," Dr. Cooper says.