Over the past 15 years, we have seen remarkable changes in our ability to care for patients with moderate to severe psoriasis. We can take people with horrific psoriasis and get them basically clear—without having to wrap them in tar or make them take time off of work.
Biologics have revolutionized our practice. They are remarkably effective treatments for psoriasis. They are all the more remarkable because along with their profound efficacy comes an extraordinary safety profile. The “no pain, no gain” paradigm is broken. Before biologics, more efficacy came with more side effects. No longer.
With biologics, new questions have arisen. With methotrexate and cyclosporine, blood work monitoring was required regularly, and we knew what blood tests were needed. But what routine lab monitoring is needed for biologics?
One psoriasis expert reported that whenever he gives anyone any medication that could affect the immune system, he gets a basic battery of laboratory tests that he repeats at intervals including: complete blood count, complete metabolic profile, urinalysis, chest x-ray, antinuclear antibody, HIV and hepatitis profile, lipid profile, and C-reactive protein.
I don’t do any of those. My plan includes just getting the baseline tuberculosis (TB) test, perhaps a hepatitis panel before tumor necrosis factor inhibitors, and then an annual evaluation for TB (asking about cough and night sweats would be enough for me, though my nurses make me order an annual formal TB test, probably at the request of the insurer). The expert suggested I should do the whole panel, saying, “You might find something, and there’s no downside.”
I found this very ironic, because clearly there’s a downside, and it isn’t just the cost of doing these lab tests. The downside is that I might find something.
Biologics don’t cause lab abnormalities. If I were to do all these labs, undoubtedly I would find some positive results, and almost surely they would be false-positive ones.1 The downside of a false positive may include scaring the patient unnecessarily, having to stop a perfectly good medication (and not being able to use it again), and additional follow-up tests. At worst, those follow-up tests could lead down the road to more morbidity.
Imagine if the white count were to drop (perhaps because of a benign viral infection the week before the test). It could lead to a bone marrow biopsy and if that found false-positive results, perhaps even to an unnecessary course of chemotherapy.
The bottom line is that there isn’t strong evidence to say you should do regular lab monitoring for patients on biologics. There is also not strong evidence to say that you shouldn’t. Whatever makes you and your patient comfortable is probably just fine.
Steven R. Feldman, MD, PhD
Chief Medical Editor
Dr Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Reference
1. van Lümig PP, Driessen RJ, Roelofs-Thijssen MA, Boezeman JB, van de Kerkhof PC, de Jong EM. Relevance of laboratory investigations in monitoring patients with psoriasis on etanercept or adalimumab. Br J Dermatol. 2011;165(2):375-382.
Over the past 15 years, we have seen remarkable changes in our ability to care for patients with moderate to severe psoriasis. We can take people with horrific psoriasis and get them basically clear—without having to wrap them in tar or make them take time off of work.
Biologics have revolutionized our practice. They are remarkably effective treatments for psoriasis. They are all the more remarkable because along with their profound efficacy comes an extraordinary safety profile. The “no pain, no gain” paradigm is broken. Before biologics, more efficacy came with more side effects. No longer.
With biologics, new questions have arisen. With methotrexate and cyclosporine, blood work monitoring was required regularly, and we knew what blood tests were needed. But what routine lab monitoring is needed for biologics?
One psoriasis expert reported that whenever he gives anyone any medication that could affect the immune system, he gets a basic battery of laboratory tests that he repeats at intervals including: complete blood count, complete metabolic profile, urinalysis, chest x-ray, antinuclear antibody, HIV and hepatitis profile, lipid profile, and C-reactive protein.
I don’t do any of those. My plan includes just getting the baseline tuberculosis (TB) test, perhaps a hepatitis panel before tumor necrosis factor inhibitors, and then an annual evaluation for TB (asking about cough and night sweats would be enough for me, though my nurses make me order an annual formal TB test, probably at the request of the insurer). The expert suggested I should do the whole panel, saying, “You might find something, and there’s no downside.”
I found this very ironic, because clearly there’s a downside, and it isn’t just the cost of doing these lab tests. The downside is that I might find something.
Biologics don’t cause lab abnormalities. If I were to do all these labs, undoubtedly I would find some positive results, and almost surely they would be false-positive ones.1 The downside of a false positive may include scaring the patient unnecessarily, having to stop a perfectly good medication (and not being able to use it again), and additional follow-up tests. At worst, those follow-up tests could lead down the road to more morbidity.
Imagine if the white count were to drop (perhaps because of a benign viral infection the week before the test). It could lead to a bone marrow biopsy and if that found false-positive results, perhaps even to an unnecessary course of chemotherapy.
The bottom line is that there isn’t strong evidence to say you should do regular lab monitoring for patients on biologics. There is also not strong evidence to say that you shouldn’t. Whatever makes you and your patient comfortable is probably just fine.
Steven R. Feldman, MD, PhD
Chief Medical Editor
Dr Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Reference
1. van Lümig PP, Driessen RJ, Roelofs-Thijssen MA, Boezeman JB, van de Kerkhof PC, de Jong EM. Relevance of laboratory investigations in monitoring patients with psoriasis on etanercept or adalimumab. Br J Dermatol. 2011;165(2):375-382.
Over the past 15 years, we have seen remarkable changes in our ability to care for patients with moderate to severe psoriasis. We can take people with horrific psoriasis and get them basically clear—without having to wrap them in tar or make them take time off of work.
Biologics have revolutionized our practice. They are remarkably effective treatments for psoriasis. They are all the more remarkable because along with their profound efficacy comes an extraordinary safety profile. The “no pain, no gain” paradigm is broken. Before biologics, more efficacy came with more side effects. No longer.
With biologics, new questions have arisen. With methotrexate and cyclosporine, blood work monitoring was required regularly, and we knew what blood tests were needed. But what routine lab monitoring is needed for biologics?
One psoriasis expert reported that whenever he gives anyone any medication that could affect the immune system, he gets a basic battery of laboratory tests that he repeats at intervals including: complete blood count, complete metabolic profile, urinalysis, chest x-ray, antinuclear antibody, HIV and hepatitis profile, lipid profile, and C-reactive protein.
I don’t do any of those. My plan includes just getting the baseline tuberculosis (TB) test, perhaps a hepatitis panel before tumor necrosis factor inhibitors, and then an annual evaluation for TB (asking about cough and night sweats would be enough for me, though my nurses make me order an annual formal TB test, probably at the request of the insurer). The expert suggested I should do the whole panel, saying, “You might find something, and there’s no downside.”
I found this very ironic, because clearly there’s a downside, and it isn’t just the cost of doing these lab tests. The downside is that I might find something.
Biologics don’t cause lab abnormalities. If I were to do all these labs, undoubtedly I would find some positive results, and almost surely they would be false-positive ones.1 The downside of a false positive may include scaring the patient unnecessarily, having to stop a perfectly good medication (and not being able to use it again), and additional follow-up tests. At worst, those follow-up tests could lead down the road to more morbidity.
Imagine if the white count were to drop (perhaps because of a benign viral infection the week before the test). It could lead to a bone marrow biopsy and if that found false-positive results, perhaps even to an unnecessary course of chemotherapy.
The bottom line is that there isn’t strong evidence to say you should do regular lab monitoring for patients on biologics. There is also not strong evidence to say that you shouldn’t. Whatever makes you and your patient comfortable is probably just fine.
Steven R. Feldman, MD, PhD
Chief Medical Editor
Dr Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Reference
1. van Lümig PP, Driessen RJ, Roelofs-Thijssen MA, Boezeman JB, van de Kerkhof PC, de Jong EM. Relevance of laboratory investigations in monitoring patients with psoriasis on etanercept or adalimumab. Br J Dermatol. 2011;165(2):375-382.
