Unforeseen adverse events associated with biotechnological medications for the treatment of psoriasis are not uncommon. Investigators from the University of Bologna in Italy have published evidence-based recommendations on the management of unforeseen events in patients with psoriasis who are treated with these therapies in Dermatologic Therapy.
According to the authors of the paper, the use of biotechnological medications for psoriasis should be avoided during pregnancy and lactation as there is currently a lack of robust data on the safety of these therapies during these times. Based on current evidence, some monoclonal antibodies may cross the placenta after the first trimester. New anti-IL23 and IL1-17 therapies should be avoided because of these concerns.
The authors suggest clinicians should speak with women with psoriasis who have become pregnant about the safety risks associated with biotechnological therapies and should evaluate whether or not to discontinue therapy. Etanercept and certolizumab are cited as agents that may not cross the placental barrier to the embryo and are suggested as safer therapeutic options for moderate-to-severe psoriasis. Few safety data on the use of biotechnologic agents during lactation exist, suggesting clinicians may wish to practice caution when considering these therapies in women who are considering breastfeeding.
The authors recommend clinicians screen patients with psoriasis for latent tuberculosis prior to and during anti-TNF-α treatment. Biologic therapies anti-TNF-α or anti-IL12/23 may be initiated ≥1 month following prophylactic therapy for latent tuberculosis, according to guidelines in the US. For patients with psoriasis who have HIV, the authors cited recent expert opinion statements that supported the consideration of anti-TNF-α, ustekinumab, and apremilast for patients who have close monitoring and control of HIV load and CD4 count.
In terms of surgical procedures, the authors stated that no interruption of biologic therapy is needed for patients with psoriasis who are set to undergo low-risk interventions. For moderate- and high-risk surgeries, the authors suggest the administration of biologic agents should be stopped 3 to 4 times the half-lives of the therapy prior to intervention. Biologic therapy could be restarted 1 to 2 weeks after surgery if the patient is free from complications.
The authors wrote that any clinician who treats psoriasis with biotechnologic therapy may experience ≥1 unexpected events, stating that “it should be good practice to know how to manage them.” Further study is needed to form a consensus-based guideline on how to manage these events in this patient population.
Sacchelli L, Magnano M, Loi C, Patrizi A, Bardazzi F. The unforeseen during biotechnological therapy for moderate‐to‐severe psoriasis: How to manage pregnancy and breastfeeding, infections from Mycobacterium tuberculosis, hepatitis B virus, hepatitis C virus, and HIV, surgery, vaccinations, diagnosis of malignancy, and dose tapering [published online April 14, 2020]. Dermatol Ther. doi:10.1111/dth.13411