Psoriasis: General priniciples for patients treated with biologics

When planning to initiate treatment of a patient with psoriasis with a biologic it is important to obtain an age appropriate history and physical examination along with an updated medication list. In addition, it is also important to obtain a reliable set of baseline laboratory studies that will allow the clinician to detect and be aware of any underlying conditions or risk factors. This is particularly important because after patients have been initiated on a biologic treatment, they are likely to be treated with other biologics or systemic therapies and it may be useful to have reliable baseline laboratory studies. A recent consensus statement from the Medical Board of the National Psoriasis Foundation addresses the appropriate monitoring of patients with psoriasis who are being treated with biologics.77 This consensus statement points out that although there is no specific guideline or single way of taking care of any patient, there are some tests that many dermatologists obtain in patients with psoriasis before commencing systemic therapies including biologics. These include a chemistry screen with liver function tests, complete blood cell count including platelet count, a hepatitis panel, and tuberculosis (TB) testing all obtained at baseline and with variable frequencies thereafter. Although there are relatively minimal data on the use of the biologics during pregnancy, 4 of the 5 agents are pregnancy category B, whereas efalizumab is pregnancy category C. All of the data for the biologics are based on studies in adults aged 18 years and older, with little data on the use of biologics for psoriasis in children younger than 18 years, with the exception of one study evaluating the safety and efficacy of etanercept in this age group (see below subsection on pediatric psoriasis within section on etanercept). While being treated with biologics, patients need to be periodically reevaluated for the development of new symptoms including infection and malignancy. Treatment with biologics is contraindicated in patients with active, serious infections. If patients develop serious infections (usually defined as an infection that requires antibiotic therapy) while being treated with a biologic agent, it is prudent to hold the biologic until the infection has resolved. 

Because biologic therapies target the immune system, it is important to use all approaches to prevent infection, including vaccinations. However, it is also possible that biologic therapies may impair the immunologic response to vaccinations. In one small study, efalizumab given before primary immunization reduced the secondary immune response to the immunizing agent.78 In contrast, patients treated with alefacept had normal immune responses to tetanus toxoid and to primary vaccination with a neo-antigen.79 Most studies evaluating the immune response to vaccinations in patients treated with TNF blockers show adequate but attenuated immune responses to pneumococcal or influenza vaccination.80-85

When developing recommendations for the use of vaccinations in patients with psoriasis being treated with biologics, it is reasonable to evaluate the standard of care in organ transplantation where standard vaccinations, including pneumococcal, hepatitis A and B, influenza, and tetanus-diphtheria are recommended before initiation of immunosuppressive therapy and transplantation.86 Once immunosuppressive therapy has begun, patients are advised to avoid vaccination with live vaccines (including varicella; mumps, measles, and rubella; oral typhoid; yellow fever) and live-attenuated vaccines (including intranasal influenza and the herpes zoster vaccine).87,88 Package inserts for several of the biologics carry similar information. In patients with juvenile rheumatoid arthritis and Crohn’s disease, vaccinations are recommended before starting etanercept89 and infliximab,90 respectively. In patients with psoriasis who need vaccination, it is preferable to perform these before initiating biologic therapy. Once patients have begun biologic therapies, physicians should consider the advantages and disadvantages of administering killed virus vaccines such as influenza. Administration of live vaccines must be avoided in patients being treated with biologics under all circumstances.


Navigate section 1 of the psoriasis guideline: Biologics

Citation note

When referencing this guideline in a publication, please use the following citation: Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB,et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008 May;58(5):826-50.  


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