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- Presentation
Lab Monitoring, Screening, and Immunization Guidance for Biologics and Small Molecule Inhibitors
Description
The talk reviewed practical lab monitoring, infection screening, and vaccination guidance before and during treatment with biologics and small molecule inhibitors. For TNF-alpha inhibitors, baseline CBC/CMP and periodic LFTs are recommended, along with TB screening before treatment and annually for risk-based patients; hepatitis B and C should also be screened pre-treatment and repeated only if risk factors or abnormal liver tests are present. IL-17 inhibitors similarly warrant baseline CBC/CMP and periodic monitoring, with pre-treatment TB and hepatitis screening despite very low TB reactivation risk. For JAK inhibitors, baseline CBC, LFTs, and often lipids are advised, with follow-up at about 12 weeks and periodically; these drugs should be avoided in significant cytopenias or severe hepatic impairment and require TB and hepatitis screening due to infection/reactivation risk. The speaker then explained TB testing algorithms using PPD or IGRA, how to evaluate positive results with chest X-ray and symptom review, and how to distinguish active from latent TB, including when biologics should be delayed or can be continued with TB treatment. Hepatitis B interpretation was reviewed by serologic patterns, with recommendations to involve hepatology for reactivation risk, prophylaxis, or monitoring, while hepatitis C workup was described as antibody testing with reflex RNA if positive. Finally, vaccination guidance emphasized not delaying needed disease treatment, giving inactivated vaccines ideally at least two weeks before therapy when possible, avoiding live vaccines or completing them at least four weeks before immunosuppression, and prioritizing influenza, COVID-19, and hepatitis B vaccines.
View moreConclusions
- Baseline CBC, CMP, and relevant infection screening are prudent before starting biologics or small molecule inhibitors, with ongoing monitoring tailored to the drug class and patient risk.
- TNF-alpha inhibitors require the most routine safety vigilance, including periodic liver tests and strong attention to tuberculosis and hepatitis B/C screening.
- IL-17 inhibitors appear to have relatively low rates of serious infectious reactivation, but pre-treatment screening and periodic lab review are still recommended.
- JAK inhibitors warrant the broadest laboratory surveillance because of risks for cytopenias, liver injury, lipid elevations, and infection reactivation.
- Negative TB screening can usually clear a patient for treatment, while a positive result should trigger chest imaging and symptom/history review to distinguish latent from active disease.
- Active tuberculosis is a contraindication to starting these therapies until treatment is completed, whereas latent TB can often be treated and the dermatologic medication started after a short lead-in with infectious disease input.
- Prior BCG vaccination or atypical mycobacterial exposure can cause false-positive PPD results, making IGRA helpful in ambiguous cases.
- Patients who convert to latent TB while already on treatment may sometimes continue the biologic or small molecule inhibitor with concurrent TB therapy and specialist oversight.
- Hepatitis B interpretation depends on the pattern of surface antigen, core antibody, and surface antibody, with acute infection requiring deferral and chronic or resolved infection requiring hepatology-guided risk management.
- Unvaccinated patients should be offered hepatitis B vaccination when appropriate, but needed treatment should not be delayed solely to complete vaccination.
- For most immunosuppressive therapies, inactivated vaccines are safe and ideally completed before treatment, whereas live vaccines should be given well in advance or avoided during therapy.
- The most important practical principle is to avoid delaying needed disease control for vaccination logistics, especially in patients with high disease burden such as hidradenitis suppurativa.
- QuantiFERON-TB Gold Plus (QFT-Plus)
- T-SPOT.TB test (T-Spot)