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- Presentation
Myth-Busting Modern Psoriasis Biologic Therapy
Description
The speaker challenges several outdated myths about modern psoriasis biologic therapy and emphasizes evidence-based, individualized decision-making. First, routine TB screening is not necessary for all patients starting IL-17 or IL-23 inhibitors; unlike TNF inhibitors, these agents have not shown meaningful TB reactivation risk, and screening should be based on patient risk factors rather than reflexive testing. Second, biologics do not need to be automatically stopped during preconception or pregnancy: psoriasis often improves in pregnancy, transplacental IgG transfer does not begin until about 13 weeks, and some agents—especially certolizumab, and often IL-23s—may be reasonable depending on the case. Third, biologics are not proven to cause cancer or worsen malignancy risk; psoriasis itself is associated with higher cancer risk, but IL-17 and IL-23 inhibitors have not shown a clear malignancy signal, even in some patients with current or prior cancer, though coordination with oncology is advised. Fourth, biologics do not always need to be held before surgery; newer guidelines suggest IL-17 and IL-23 inhibitors can often be continued, with case-by-case discussion for higher-risk procedures. Finally, biosimilars are not less safe than branded biologics; real-world data show comparable serious adverse event rates and similar effectiveness overall, though patients switched from originator drugs may need closer support during transition. The overall message is to avoid reflexive practices based on outdated assumptions and to tailor treatment to the individual patient.
View moreConclusions
- Routine TB screening is not necessary for most patients starting IL-17 or IL-23 inhibitors, and testing should be reserved for those with individual risk factors.
- IL-17 and IL-23 biologics do not appear to meaningfully increase TB reactivation risk, unlike TNF inhibitors.
- Psoriasis often improves during pregnancy, so systemic therapy should not be reflexively stopped before conception or early in pregnancy.
- First-trimester biologic exposure is less concerning than commonly assumed because significant placental IgG transfer begins later in gestation.
- Certolizumab appears to be the safest biologic option in pregnancy because it has minimal placental transfer, while some TNF inhibitors may need to be stopped later in pregnancy.
- Biologics do not seem to increase overall cancer risk in psoriasis patients, including those with a prior malignancy.
- IL-17 and IL-23 inhibitors appear acceptable, and often preferred, in patients with active or previous cancer when coordinated with oncology.
- Most biologics, especially IL-17 and IL-23 agents, can likely be continued through many surgeries without a major increase in postoperative complications or infection risk.
- IL-17 and IL-23 inhibitors do not need to be routinely stopped for surgery, though perioperative decisions should be individualized with the surgeon.
- Biosimilars are generally as safe as branded biologics and are a cost-effective treatment option for psoriasis.
- Biosimilars may perform best when used as first-line therapy, while switching from a brand to a biosimilar can be associated with more discontinuation and need for closer follow-up.
- Modern psoriasis care should be guided by current evidence rather than outdated assumptions about biologic risk.
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