Safety Considerations and Biologic Treatment Selection in HS

In "Safety Considerations and Biologic Treatment Selection in HS," our experts turn to the safety profile of each biologic class.

Dr. Bush outlines the safety screening she performs before starting any HS biologic. TNF-alpha inhibitors carry a black box warning for severe infection and lymphoma or malignancy risk, so she screens for demyelinating conditions such as Guillain-Barre syndrome or multiple sclerosis, which are contraindications, and for heart failure, recalling a case early in her career where a TNF inhibitor worsened a patient's heart failure. For secukinumab and bimekizumab, she screens for inflammatory bowel disease and discusses candidiasis risk, particularly with bimekizumab, along with periodic liver function monitoring since enzymes can rise and typically normalize. None of these agents are used in pregnancy. Dr. Bush proactively tells patients what side effects to expect and when to call her, which she believes prevents unnecessary emergency room visits for manageable issues like oral candidiasis. Chao agrees, adding that most candidiasis cases in the bimekizumab trials were mild-to-moderate and resolved within days once treated, so forewarning patients avoids frightening surprises. Reflecting on real-world experience, Dr. Bush notes many insurers now push adalimumab biosimilars, that patients do well across all three biologics, and that bimekizumab tends to act fastest. Chao agrees that response is unpredictable between anti-TNF and IL-17 agents until a patient is actually treated. Applying this to the case 1 patient, Dr. Bush would favor bimekizumab or secukinumab over a TNF inhibitor, since TNF inhibitors work less well on draining tunnels, which this patient has. Given the patient's apparent urgency, she leans toward bimekizumab for faster control, unless the patient reports recurrent yeast infections, in which case she would choose secukinumab instead. Chao adds that he preemptively prescribes fluconazole for patients prone to recurrent candidiasis, and agrees either agent is reasonable here, calling today's options a dramatic improvement over what existed fifteen years ago.

The next episode, "Monitoring Biologic Response in HS," follows patients once therapy begins, from setting expectations to catching subtle signs of pigment change.