LAS VEGAS – For a physician starting a patient on a systemic agent to treat psoriasis, deciding on risk factor screening and management strategies can be confusing. Who gets checked for what? Why? How often?
With a dearth of evidence to guide them, physicians should use what they know about psoriasis itself, as well as patient risk factors and the inherent risks of a given systemic therapy to guide screening, according to Dr. Kristina Callis Duffin of the department of dermatology, University of Utah, Salt Lake City.
Courtesy of the Centers for Disease Control and Prevention (CDC)
Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Duffin said that in her practice, this means that all patients being considered for systemic therapy get baseline labs as recommended by the drug manufacturer, and risk-focused monitoring for cardiovascular disease, infection, and cancer. Basically, she noted, the strategy is, “How can we be effective at monitoring and surveying for those ‘bad guys’– those complications of therapy?”
“Some of this is really about using common sense and being a good physician,” she added.
To obtain a pertinent history, it’s worthwhile to formulate a directed intake questionnaire, Dr. Duffin said. Screening items should include history of recurrent infections; hepatitis, HIV, and TB status and risk; travel history; cardiovascular history, including lipid status; history of any liver or kidney problems; history and risk of diabetes mellitus; depression; personal or family history of multiple sclerosis; and history of cancer, including skin cancer, and blood disorders.
The social history should include pregnancy status and birth control method for women (as appropriate); and alcohol use for all patients. Patients should be current with age-appropriate recommended immunizations and cancer screenings.
Obtaining baseline lab tests for all patients before they start treatment with a systemic agent affords the opportunity to detect common metabolic abnormalities, such as diabetes, liver or kidney disease, and dyslipidemia, as well as rare but serious blood abnormalities, Dr. Duffin said. This approach respects the fact that “there is no question that cardiovascular risk factors are overrepresented in the moderate to severe psoriasis population.”
Published TB screening guidelines have universally recommended screening before initiating a biologic agent with a tuberculin skin test, unless the patient has had the BCG vaccine or is immunosuppressed. From there, interpretation of the tine test and further screening requires knowing the patient: “It’s all about pretest probability,” said Dr. Duffin, adding that physicians should not be afraid to use infectious disease consultants to help them sort out tricky cases.
In terms of ongoing management, communication and coordination are key. Continue to ask patients about symptoms of psoriatic arthritis, and make sure that you work with the patient’s primary care provider so that cardiovascular risk management, malignancy screening, and immunizations don’t fall through the cracks, she advised.
“Have a high index of suspicion for infection,” including deep fungal infections, she added. Though the literature does not report frequent cases of serious fungal infections, “there’s no question cases are unreported or numbers can be unclear in the registries.” Patients should know early signs of infection and know to seek care right away.
Patients should know to defer live vaccines, and the physician managing the care of psoriasis should be included in the planning and management process for any type of surgery, to oversee biologic administration. While probably slight, the risk of infection should be weighed against the risk of loss of efficacy in psoriasis or psoriatic arthritis treatment, Dr. Duffin said.
The baseline risk of solid tumors is elevated in patients with psoriasis, but “is not definitively elevated in patients on biologics,” she commented. The risk of nonmelanoma skin cancer, however, is definitely elevated for patients on biologic therapies, so an annual skin survey is a must for these patients, she said.
“Should we be discussing immunizations with our patients? Absolutely,”she added. All patients need the influenza vaccine and the pneumococcal vaccine, and for live virus immunizations, the dermatologist should coordinate administration with the primary care physician.
Managing these risks effectively can make a big difference in quality of life for patients who are able to start and stay on systemic therapy, said Dr. Duffin. The many risks of not treating psoriasis appropriately include not only the significant psychosocial impact, but also progression of psoriatic arthritis, progression of skin disease, and increased risk of heart disease and other cardiovascular comorbidities. “Our job is to treat to patient satisfaction and the best possible quality of life. A lot of this is about anticipation and communication,” she said.