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- Presentation
Guidelines for Baseline Screening and Monitoring Before Psoriasis Biologics
Description
The speaker reviews current guidance for baseline screening and monitoring before starting psoriasis biologics, emphasizing safe prescribing and the need to avoid excessive testing that may delay treatment or cause unnecessary anxiety. For most patients, baseline CBC, CMP, hepatitis C, hepatitis B, and tuberculosis screening are recommended, while HIV testing is left to clinician discretion based on risk factors. Newer guidance suggests that routine latent TB testing is not required for patients starting IL-17 or IL-23 inhibitors unless special risk factors are present, though TB screening remains important for TNF inhibitors. Hepatitis B interpretation is reviewed in detail, including when to vaccinate, monitor, or refer to hepatology depending on serologies and risk of reactivation. Additional considerations include screening for endemic fungal infections in patients with relevant symptoms or epidemiologic exposure, checking for heart failure before TNF inhibitors, avoiding IL-17 inhibitors in inflammatory bowel disease, assessing candidiasis risk with IL-17 agents, ensuring age-appropriate cancer and skin cancer screening, screening for multiple sclerosis before TNF inhibitors, and avoiding certain agents in patients with severe suicidal ideation. Ongoing monitoring is tailored by drug class, with annual TB testing and selected lab or viral load monitoring especially for TNF inhibitors and infliximab.
View moreConclusions
- Routine baseline screening for psoriasis biologics should be more targeted than broad, indiscriminate testing because many traditional tests have limited evidence and may add cost, false positives, anxiety, and treatment delays.
- CBC, CMP, hepatitis B and C testing, and TB screening remain standard baseline considerations overall, but HIV testing is best guided by patient-specific risk rather than universally mandated.
- For IL-17 and IL-23 inhibitors, routine latent TB screening may not be necessary in low-risk patients, whereas TB screening remains important for TNF inhibitors and for patients with epidemiologic or clinical risk factors.
- Hepatitis B screening is still important before biologic therapy, especially with TNF inhibitors, and serology should guide whether vaccination, monitoring, specialist consultation, or antiviral management is needed.
- Patients with symptoms or exposure risk for endemic fungal infection, such as coccidioidomycosis or histoplasmosis, may need additional targeted workup even though routine universal screening is not generally recommended.
- Before starting TNF inhibitors, clinicians should assess for heart failure, avoid these agents in severe NYHA class III/IV disease, and coordinate cardiac evaluation when indicated.
- Interleukin-17 inhibitors should generally be avoided in patients with inflammatory bowel disease, and candidiasis risk should be considered with these agents.
- Age-appropriate malignancy screening and skin examinations remain prudent, while brodalumab should be avoided in patients with significant suicidal ideation history and TNF inhibitors should be avoided in patients with multiple sclerosis history.
- Overall, the presentation argues for individualized, risk-based monitoring and pre-treatment evaluation rather than uniform blanket screening for every biologic-treated psoriasis patient.
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- Doherty et al. JAAD. 2008 Aug; 59(2):209-17.